Search

Background : Sarcopenia is defined as low muscle mass, with low muscle strength or low physical performance. The skeletal muscle mass (or density) and strength are inversely associated with cardiovascular risk factors. We aim to determine the relationship between skeletal muscle characteristics (strength, mass, area), and cardiovascular risk factors in a population with lower extremity artery disease (LEAD) Methods : An observational, prospective study including patients with LEAD was conducted from January 2018 to December 2020. The cardiovascular risk factors and anthropometric measurements were prospectively registered. The skeletal muscle characteristics (area, density/mass and strength) were analysed. The skeletal muscle area and density were quantified with a CT scan. The strength was determined with a Jamar® hydraulic hand dynamometer. Results : 96 patients with LEAD with 67.70± 10.11 years-old were enrolled in the study. The most prevalent cardiovascular risk factor was hypertension, followed by dyslipidemia and diabetes. Patients with diabetes had a lower handgrip strength and skeletal muscle density, when compared with patients without diabetes (strength: 19.67± 9.98 kgf versus 26.79 ± 11.80 kgf, p=0.002 and skeletal muscle density: 10.58 ± 17.61 HU versus 18.17 ± 15.33 HU, p=0.032). There was a trend for the association between the presence of cardiovascular risk factors (hypertension and dyslipidemia) and a decrease in skeletal muscle density and strength (density: hypertension: 13.46 ± 16.74 HU versus 20.38 ± 11.63 HU p=0.055; dyslipidemia: 13.57 ± 17.16 HU versus 17.74 ± 13.00 HU p=0.315; strength- hypertension: 22.55 ± 10.08 kgf versus 27.58 ± 15.11 p= 0.073; dyslipidemia: 22.80 ± 10.52 kgf versus 25.28 ± 13.14 kgf p=0.315). Interestingly, we found that smokers had a favorable skeletal muscle characteristic, which could be explained by the higher prevalence of diabetes in non-smokers. Conclusions : The indicators of skeletal muscle dysfunction (strength and density) are associated to the presence of diabetes in patients with LEAD. Therapeutic strategies to improve the skeletal muscle characteristics could have a role in improving LEAD risk factors, particularly diabetes.

OBJECTIVE For same-day discharge lower extremity arterial disease (LEAD) endovascular procedures, femoral manual compression could be an alternative to arterial closure devices. The aim of this study was to assess the security and efficacy of same-day discharge after manual compression in patients treated for LEAD endovascular revascularization with 5F sheath. METHODS FREEDOM OP was a national multicenter, prospective, single arm study. Patients with symptomatic LEAD (Rutherford 2 to 5) and eligible for same-day discharge were included. The primary endpoint was the total in-hospital admission rate, which includes overnight surveillance and rehospitalization rate at 1 month. RESULTS Between September 2017 and August 2019, 114 patients were included. The mean age of the patients was 66 ± 10 years and most of them were claudicant (103; 94%). Mainly femoropopliteal lesions were treated (178; 70%) and the technical success was 97%. One hundred forty two 5F stents and fifty one 5F drug coated balloon were delivered. The mean manual compression duration was 13 ± 4 min. Major access-related complications rate was 4.5%. Total in-hospital admission rate was 11%. Seven patients had overnight surveillance and 5 were rehospitalized (2 for the target lesion). No rehospitalisation was carried out within 24 hours after discharge. No major cardiovascular event, including death, was observed. The patients were significantly improved in term of clinical status (p

Background: Transcatheter aortic valve replacement is an established treatment option for patients with severe symptomatic aortic stenosis and is most commonly performed through the transfemoral access route. Percutaneous access site closure can be achieved using dedicated plug-based or suture-based vascular closure device (VCD) strategies, but randomized comparative studies are scarce. Methods: The CHOICE-CLOSURE trial (Randomized Comparison of Catheter-based Strategies for Interventional Access Site Closure during Transfemoral Transcatheter Aortic Valve Implantation) is an investigator-initiated, multicenter study, in which patients undergoing transfemoral transcatheter aortic valve replacement were randomly assigned to vascular access site closure using either a pure plug-based technique (MANTA, Teleflex) with no additional VCDs or a primary suture-based technique (ProGlide, Abbott Vascular) potentially complemented by a small plug. The primary end point consisted of access site– or access-related major and minor vascular complications during index hospitalization, defined according to the Valve Academic Research Consortium-2 criteria. Secondary end points included the rate of access site– or access-related bleeding, VCD failure, and time to hemostasis. Results: A total of 516 patients were included and randomly assigned. The mean age of the study population was 80.5±6.1 years, 55.4% were male, 7.6% of patients had peripheral vascular disease, and the mean Society of Thoracic Surgeons score was 4.1±2.9%. The primary end point occurred in 19.4% (50/258) of the pure plug-based group and 12.0% (31/258) of the primary suture-based group (relative risk, 1.61 [95% CI, 1.07–2.44], P =0.029). Access site– or access-related bleeding occurred in 11.6% versus 7.4% (relative risk, 1.58 [95%CI: 0.91–2.73], P =0.133) and device failure in 4.7% versus 5.4% (relative risk, 0.86, [95% CI, 0.40–1.82], P =0.841) in the respective groups. Time to hemostasis was significantly shorter in the pure plug-based group (80 [32–180] versus 240 [174–316] seconds, P Conclusions: Among patients treated with transfemoral transcatheter aortic valve replacement, a pure plug-based vascular closure technique using the MANTA VCD is associated with a higher rate of access site– or access-related vascular complications but a shorter time to hemostasis compared with a primary suture-based technique using the ProGlide VCD. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04459208.

Aim The purpose of this study is a comparative analysis of the degree of disease acceptance and social support in patients with peripheral vascular diseases and other medical conditions treated in surgery ward. Design A cross‐sectional study. Methods This cross‐sectional study compares disease acceptance and social support in a group of 212 patients with peripheral vascular diseases and other conditions treated in surgery ward. A standardized Acceptance of Illness Scale (AIS) and Social Support Scale were used to collect the research data. Results Overall, on the AIS, 14% of patients with surgical diseases and 34% of patients with vascular diseases had a low disease acceptance rate. A high level of support was demonstrated in 41% of study participants with surgically treated diseases and in 17% of participants with vascular diseases.

Our aim was to investigate whether the previously observed higher contrast-to-noise ratio (CNR) and better image quality of Digital Variance Angiography (DVA) - compared to Digital Subtraction Angiography (DSA) - can be used to reduce radiation exposure in lower limb X-ray angiography. This prospective study enrolled 30 peripheral artery disease patients (mean ± SD age 70 ± 8 years) undergoing diagnostic angiography. In all patients, both normal (1.2 µGy/frame; 100%) and low-dose (0.36 µGy/frame; 30%) protocols were used for the acquisition of images in three anatomical regions (abdominal, femoral, crural). The CNR of DSA and DVA images were calculated, and the visual quality was evaluated by seven specialists using a 5-grade Likert scale. For investigating non-inferiority, the difference of low-dose DVA and normal dose DSA scores (DVA30-DSA100) was analyzed. DVA produced two- to three-fold CNR and significantly higher visual score than DSA. DVA30 proved to be superior to DSA100 in the crural region (difference 0.25 ± 0.07, p p = 0.435) and abdominal (− 0.10 ± 0.09, p = 0.350) regions. Our data show that DVA allows about 70% reduction of DSA-related radiation exposure in lower limb X-ray angiography, providing a potential new radiation protection tool for the patients and the medical staff.

Background The effect of lumbar spinal stenosis (LSS) and peripheral vascular disease (PVD), which occurs with similar degenerative conditions, when seen together, has not been studied. The aim of this study is to examine and compare the relationship between pain, balance, disability, fear of falling, and kinesiophobia in LSS patients with intermittent vascular claudication (IVC). Methods Seventy-two patients diagnosed with LSS using magnetic resonance imaging participated in this study. Thirty-five patients with IVC symptoms and showing vascular lesions by lower extremity venous and arterial Doppler ultrasonography imaging were included in the IVC-LSS group. The pain, static balance, dynamic balance, disability, fear of falling, and kinesiophobia were evaluated using the numeric rating scale, single leg stance test, Time Up and Go (TUG), the Oswestry Disability Index (ODI), Fall Efficacy Scale-International (FES-I), and Tampa Scale for Kinesiophobia (TSK), respectively. Results Age and female sex were found to be higher in the IVC-LSS group (P = 0.024; P = 0.012). The IVC-LSS group had a shorter single leg stance time and TUG test duration, pain intensity, ODI, FES-I, and TSK scores were higher than patients with LSS (P = 0.001). Pain, fear of falling, and kinesiophobia were moderately correlated with disability in the IVC-LSS group. No relationship was found between pain and dynamic balance. Also, the pain was not related to kinesiophobia. Conclusions The findings indicated that IVC causes loss of balance and an increase in pain, disability, fear of falling, and kinesophobia in patients with LSS.

Objective: The aim of this study was to contribute to the issue of “Who should we perform Doppler ultrasonography on?” and determine the contribution of comorbid diseases to the development of carotid artery stenosis (CAS) and pre-operative CAS by examining comorbid diseases in patients undergoing coronary artery bypass graft operation (CABG) and also discussing the effect of carotid stenosis levels on postoperative stroke.Method: Between 2011-2015, a total of 921 patients who underwent cardiac surgery retrospectively were examined. Of these, 594 CABG patients aged 60 and over who underwent preoperative carotid Doppler examination were analyzed.Results: Sixty-five percent of patients were male, and 35% were female. The mean age was 69.3 years. Sixty-nine percent of patients were in the 0-29% stenosis group, 12.9% in the 30-49% group, 14.6% in the 50-69% group, 3% in the 70-99% group, and 0.3% in the 100% occlusion group. Peripheral artery disease (PAD), age, gender, and diabe-tes mellitus (DM) were found to have significant (P < 0.05) effects on the occurrence of CAS. CAS increased by 0.9% with an increase of one year in age, 10.8% with the presence of PAD, 3% with male sex, 3.8% with presence of chronic obstructive pulmonery disease (COPD), 1.9% with presence of left main coronary disease (LMCAD), and 0.9% with pres-ence of hypertension. In the decision tree analysis, the rate of 50% and above CAS in the presence of PAH + DM and age older than 65 years was 62.5%. Cerebrovascular accident (CVA) distribution was 2.1% in the 0-29% group, 2.5% in the 30-49% group, 4.5% in the 50-69% group, and 11.1% in the 70-99% group. Postoperative CVA was not observed in 10 patients who underwent carotid endarterectomy (CE). Postoperative CVA developed in six patients with 50% or more stenosis who did not undergo CE. Conclusion: For the preoperative detection of CAS in patients undergoing CABG, the association of advanced age, PAD, DM, male gender, COPD, LMCAD, and hyperten-sion risk factors should be considered. We suggest that carotid screening should be performed in those over 65 years of age and with PAD+DM. Studies with large populations are needed to observe the effects of aortic atherosclerosis load, surgical proce-dure, and unilateral/bilateral CAS presence on the development of stroke in patients with severe CAS and postoperative CVA.

As the prevalence of peripheral vascular disease (PVD) continues to increase nationwide, studies demonstrating its effects following primary total knee arthroplasty (TKA) are limited. Therefore, the purpose of this study was to evaluate whether patients with PVD have higher rates of: 1) in-hospital lengths of stay (LOS); 2) readmissions; 3) medical complications; 4) implant-related complications; and 5) costs of care.Using a nationwide database, patients with PVD undergoing primary TKA were identified and matched to controls in a 1:5 ratio by age, sex, and medical comorbidities. The query yielded 1,547,092 between the cohorts. Outcomes analyzed included: in-hospital LOS, readmission rates, complications, and costs of care. A p-value less than 0.004 was considered statistically significant.PVD patients had significantly longer in-hospital LOS (4-days vs. 3-days, p 0.0001). Additionally, the study cohort had a higher incidence and odds (OR) of readmissions (20.5 vs. 15.2%; OR: 1.43, 95% CI: 1.42-1.45, p 0.0001), medical complications (2.46 vs. 1.32%; OR: 1.88, CI: 1.83-1.94, p 0.0001), and implant-related complications (3.82 vs. 2.18%; OR: 1.78, CI: 1.26-1.58, p 0.0001). Additionally, the study found patients with PVD had higher day of surgery (p 0.0001) and 90-day costs of care (p 0.0001).After adjusting for confounding variables the results of the study show patients with PVD undergoing primary TKA have longer in-hospital LOS; in addition to higher rates of complications, readmissions, and costs of care. The study can be utilized by orthopaedists to adequately counsel patients of the potential complications following their procedure.

Background Patients with chronic iliofemoral venous obstructive lesions that often require stenting extending below the inguinal ligament. However, the issue of stents crossing the inguinal ligament is currently controversial. Some guidelines suggest that it should be avoided, and some guidelines suggest that in order to ensure adequate flow, the inguinal ligament can be crossed if necessary. The aim of this study was to evaluate the technical aspects and examine patency rates of stent placement across the inguinal ligament for managing iliofemoral venous obstruction. Methods A retrospective analysis of 127 patients with chronic iliofemoral venous obstruction were treated with interventional surgery in a single institution from January 2012 to January 2018 was conducted. All patients underwent balloon dilatation and placement of at least 2 stents extending below inguinal ligament. Inflow condition, technical success, operation duration, stent patency rates, anticoagulant selection and duration, and complications were recorded after the interventions. Results The technical success rate was 100%. No major perioperative complications occurred. The mean number of stents was 2.14 ± 0.37. Follow up periods ranged from 12 to 60 months (28.79 ± 10.90 months). Overall cumulative primary, assisted primary, and secondary stent patency rates were 81.9%, 90.5%, and 92.9% at 12 months and 70.4%, 80.9%, and 86.0% at 24 months, and 64.2%, 72.3%, and 74.3% at 36months, respectively. Cumulative patency rates at 12 months, 24 months and 36 months were significantly greater in the patients with “good” inflow as compared to “fair” inflow. The symptoms of all patients improved. None of the stents were compressed, fractured or migrated. Conclusions Stenting across the inguinal ligament for treatment of the patients with chronic iliofemoral venous obstruction was a feasible and safe treatment with good patency and clinical results in short and midterm follow up, and stents with good inflow have better patency.

Objective: Local intramuscular transplantation of granulocyte colony-stimulating factor (G-CSF)-mobilised peripheral blood mononuclear cells (PB-MNC) has been shown to be effective for treating patients with no-option critical limb ischaemia (CLI) who are not considered suitable to undergo surgical bypass or percutaneous transluminal angioplasty. The aim of this study was to investigate the effectiveness and safety of PB-MNCs as a treatment for no-option CLI patients. Method: This prospective cohort study was conducted between April 2013 and December 2017. Patients with no-option CLI were treated with G-CSF 5–10 µg/kg/day for 3 days. PB-MNCs (7.1±2.2×10 10 ) with CD34+ cells (2.1±1.2×10 8 ) were collected by blood cell separator and then injected into the calf or thigh of ischaemic limbs. Ankle–brachial index, toe–brachial index and transcutaneous oxygen tension were recorded at 1 and 3 months after injection. The amputation rate and the wound healing rate were also recorded. Results: Eight patients took part in the study. Two patients experienced rest pain relief 1 month after PB-MNC therapy. Five patients had healed ulcer at 6 months after PB-MNC therapy. Limb ischaemia did not improve after PB-MNC therapy in one patient. Below-knee amputation was performed in that patient due to extension of gangrene. Two patients required reinjection of PB-MNCs because of recurrence of ischaemic ulcer. The limb salvage rate after 1 year was 87.5%. Conclusion: Local intramuscular transplantation of G-CSF-mobilised PB-MNCs might be a safe and effective treatment for no-option CLI patients.

Inflammation is an early feature of acute limb ischaemia (ALI), hence the potential prognostic significance of inflammatory biomarkers. This study aimed to assess the value of pre-operative inflammatory biomarkers, specifically the neutrophil to lymphocyte ratio (NLR) and the platelet to lymphocyte ratio (PLR), for predicting an adverse outcome after revascularisation for ALI.All patients submitted to lower limb revascularisation for Rutherford IIa or IIb ALI at the authors' institution between 2009 and 2019 were screened retrospectively. Pre-operative NLR and PLR were analysed, along with other known prognostic factors. Primary outcome was the composite endpoint of 30 day death or amputation.A total of 345 patients were included, 84 of whom suffered the primary outcome (24.3%). The median follow up was 23.1 months (3.1 - 52.2). Higher age (OR 1.05 per year increase, 95% CI 1.01 - 1.09), diabetes (OR 2.63, 95% CI 1.14 - 6.06), Rutherford grade IIb vs. IIa (OR 5.51, 95% CI 2.11 - 14.42), higher NLR (OR 1.28 per unit increase, 95% CI 1.12 - 1.47), and fasciotomy need (OR 3.44, 95% CI 1.14 - 10.34) were independently associated with 30 day death or amputation, whereas pre-operative statin or anticoagulant medication were associated with a risk reduction (OR 0.23, 95% CI 0.53 - 0.96 and OR 0.20, 95% CI 0.05 - 0.84, respectively). PLR did not show an independent effect on this population. Pre-operative NLR presented a good discriminative ability (AUC 0.86, 95% CI 0.82 - 0.90). A cut off NLR level ≥ 5.4 demonstrated a 90.5% sensitivity and 73.6% specificity for 30 day death or amputation. Kaplan-Meier analysis showed that patients with pre-operative NLR ≥ 5.4 had significantly lower 30 day, six month and one year amputation free survival when compared with those with NLR5.4 (64.8 ± 4.0%, 44.1 ± 4.1%, and 37.5 ± 4.1% vs. 98.5 ± 0.9%, 91.9 ± 2.0%, and 85.9 ± 2.5%, log rank p.001).In this study, higher pre-operative NLR was associated with 30 day death or amputation following intervention for Rutherford grade IIa or IIb ALI. NLR potentially stands as a simple, widely available and inexpensive biomarker that can refine decision making and possibly contribute to ALI morbidity and mortality reduction.

As a respiratory viral infection caused by a novel coronavirus, COVID-19 became rapidly pandemic within a few months. Despite the wide range of manifestations and organ involvement in COVID-19 patients, the exact pathogenesis of severe and fatal types of COVID-19 and causes involved with the individual base of the disease is not yet understood. Several studies have reported clinical, laboratory and histopathological data in favor of vascular injury in multiple organs of critically ill patients with COVID-19 as a result of hyperactive immune response, inflammation and cytokine storm. Also, both clinical and histopathological evidence points to such vascular involvements in the skin. Given the ease of clinical examinations and skin biopsy and the lower risks of transmission of COVID-19 to healthcare workers, the present review article was conducted to investigate the vascular skin manifestations of COVID-19 patients clinically and/or histopathologically as helpful clues for better understanding the pathogenesis and predicting the prognosis of the disease, especially in severe cases. This article is protected by copyright. All rights reserved.

Summary Background Radiation therapy causes histopathologic changes in tissues, including fibrosis, loss of tissue planes, and vascular damage, which can lead to chronic wound formation. Patients with nonhealing, irradiated wounds and comorbidities that affect microvasculature suffer a "double hit", which leads to delayed wound healing. Local wound care and grafts are commonly insufficient. In this study, we evaluated limb salvage outcomes and long-term complications after free tissue transfer (FTT) in patients with chronic, irradiated leg wounds. Methods We retrospectively reviewed patients with irradiated lower extremity wounds who underwent FTT from 2012 to 2017. Primary outcomes included limb salvage, ambulation, and overall flap success. Reconstruction involved complete excision of irradiated tissue and coverage with well-vascularized tissue. Results Seven free flaps in six patients were identified. Average age was 68.4 years and average BMI was 27.8 kg/m2. Comorbid conditions included hypertension (57.1%), peripheral vascular disease (57.1%), underlying hypercoagulability (42.9%), diabetes (14.3%), and tobacco use (14.3%). Wounds were present for an average of 25.5 months prior to FTT. Donor sites included anterolateral thigh (71.4%), vastus lateralis (14.3%), and latissimus dorsi (14.3%). Overall flap success rate was 100% with one patient requiring reoperation for dehiscence. Limb salvage rate was 85.7% with one patient undergoing elective amputation due to pain. All patients could ambulate (one used a prosthesis) at a mean follow-up time of 1.4 years. Conclusions Radiation therapy in a comorbid population often leads to the formation of chronic nonhealing wounds. We advocate for earlier consideration of FTT to provide healthy vascularized tissues, thereby avoiding prolonged wound care and patient burden. Successful limb salvage outcomes can be achieved.

Objective. Two dimensional (2D) perfusion angiography is a method that provides quantitative foot perfusion information from standard digital subtraction angiography acquisitions. The aim of this study was to test the reliability of this method in patients with chronic limb threatening ischaemia (CLTI) by investigating repeatability, and intra-observer and interobserver agreement.Methods: Twenty patients with CLTI and a below the knee endovascular revascularisation were included in a prospective clinical study. Prior to treatment two perfusion angiography runs were acquired with a five minute interval without performing an intervention. In these recordings, regions of interest were selected and time density curves and perfusion parameters were determined. To investigate intra-observer agreement one observer performed five measurements on the same acquisition for each patient. To investigate interobserver agreement three observers performed measurements on the same acquisition for each patient.Results were presented in Bland-Altman plots and as the intraclass correlation coefficient per parameter. Results: Two patients were excluded from repeatability analyses because of major motion artefacts. Repeatability analyses of the 18 remaining patients showed excellent correlation for every parameter (> .96). Intra-observer and interobserver agreement for all 20 patients were excellent for all parameters (1.00).Conclusion: Repeatability and intra-observer and interobserver agreement of 2D perfusion angiography in patients with CLTI were found to be excellent. It is therefore a reliable tool when used according to the standardised methods described in this study.

ObjectiveIn patients with chronic coronary or peripheral artery disease enrolled in the Cardiovascular Outcomes for People Using Anticoagulation Strategies trial, randomised antithrombotic treatments were stopped after a median follow-up of 23 months because of benefits of the combination of rivaroxaban 2.5 mg two times per day and aspirin 100 mg once daily compared with aspirin 100 mg once daily. We assessed the effect of switching to non-study aspirin at the time of early stopping.MethodsIncident composite of myocardial infarction, stroke or cardiovascular death was estimated per 100 person-years (py) during randomised treatment (n=18 278) and after study treatment discontinuation to non-study aspirin (n=14 068).ResultsDuring randomised treatment, the combination compared with aspirin reduced the composite (2.2 vs 2.9/100 py, HR: 0.76, 95% CI 0.66 to 0.86), stroke (0.5 vs 0.8/100 py, HR: 0.58, 95% CI 0.44 to 0.76) and cardiovascular death (0.9 vs 1.2/100 py, HR: 0.78, 95% CI 0.64 to 0.96). During 1.02 years after early stopping, participants originally randomised to the combination compared with those randomised to aspirin had similar rates of the composite (2.1 vs 2.0/100 py, HR: 1.08, 95% CI 0.84 to 1.39) and cardiovascular death (1.0 vs 0.8/100 py, HR: 1.26, 95% CI 0.85 to 1.86) but higher stroke rate (0.7 vs 0.4/100 py, HR: 1.74, 95% CI 1.05 to 2.87) including a significant increase in ischaemic stroke during the first 6 months after switching to non-study aspirin.ConclusionDiscontinuing study rivaroxaban and aspirin to non-study aspirin was associated with the loss of cardiovascular benefits and a stroke excess.Trial registration numberNCT01776424.

Learning objectives Peripheral artery disease (PAD) typically refers to atherosclerotic narrowing and/or occlusion of all arterial disease other than coronary arteries and the aorta (carotid and vertebral arteries, coeliac and mesenteric arteries, renal arteries and upper and lower limb arteries) (figure 1). As a manifestation of systemic atherosclerosis, PAD is associated with greatly increased cardiovascular morbidity and mortality and impairment in quality of life. Because of the frequent overlap between ischaemic heart disease and PAD, cardiologists are in a unique position to screen, diagnose and treat PAD. The body of clinical evidence in patients with PAD is not as robust as the evidence in patients with heart disease, however the treatment goals are similar for both coronary artery disease (CAD) and PAD: to prevent ischaemic outcomes with lifestyle changes and medical therapy and to weigh the risks and benefits of revascularisation (Table 1). This article reviews the basic evaluation and management of the most common types of PAD from a cardiologist’s perspective. Figure 1 Common sites of disease in patients with peripheral artery disease. View this table: Table 1 Parallel concepts in care in patients with CAD and PAD The epidemiology for different patterns of PAD (carotid artery disease, upper extremity artery disease, mesenteric artery disease, renal artery disease and lower extremity artery disease) are varied depending on population of interest. They all share common risk factors for atherosclerosis, such as smoking, hypertension, dyslipidaemia, diabetes and autoimmune/inflammatory conditions such as systemic lupus erythematosus and rheumatoid arthritis. All patients with PAD should be screened for …

Background Surgical treatment of peripheral vascular malformations is widely performed as primary and secondary treatments. Excellent results have been reported; however, it is thought that complications are likely to occur because of damage to adjacent structures. This systematic review aimed to elucidate the indications and outcomes of surgical treatment of vascular malformations. Methods PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies reporting outcomes of surgery in at least 15 patients with a single type of peripheral soft-tissue vascular malformation. The authors extracted data on patient and lesion characteristics, treatment characteristics, and outcomes (including complications). Meta-analysis was conducted on recurrence and complication rates. Results A total of 3042 articles were found, of which 24 were included: nine studies on arteriovenous malformations, seven on venous malformations, and eight on lymphatic malformations, totaling 980 patients. Meta-analyses showed pooled proportions for recurrences of 11 percent in arteriovenous malformations, 5 percent in venous malformations, and 9 percent in lymphatic malformations. Pooled proportions of major complications were 9 percent for arteriovenous malformations, 3 percent for venous malformations, and 1 percent for lymphatic malformations. The authors found a 5 percent pooled recurrence proportion in total resections, compared with 28 percent in subtotal resections. The pooled odds ratio for recurrence in total and subtotal resections showed a significant lower recurrence rate after total resection (odds ratio, 0.14, p = 0.02). Conclusions Surgical treatment of vascular malformations appears to be effective and safe in many cases. However, it seems that surgery is performed predominantly in small lesions, and subtotal resection has a higher risk of recurrence than total resection.

A 75-year-old man admitted with IgG λ-type myeloma with creatinine level of 2.3 mg/dL. Serum lactate dehydrogenase level and platelet count were normal. Urinalysis demonstrated massive proteinuria dominated by albuminuria. Weekly bortezomib and dexamethasone therapy were started to treat myeloma but failed to be continued because of rapid deterioration of renal function and increase in proteinuria 1 week after the treatment. His renal function exacerbated to require hemodialysis for a month. There was no clinical evidence of tumor lysis syndrome or thrombocytopenia throughout the course of his acute kidney injury (AKI). After he became dialysis independent, a renal biopsy was performed to clarify myeloma-related renal involvement and the cause of AKI. As a result, IgG2-λ monoclonal immunoglobulin deposition disease (MIDD) and severe endothelial injury were revealed. There was no evidence of cast nephropathy. Bortezomib-induced glomerular microangiopathy (GMA) superimposed on MIDD. Bortezomib has a potential risk to cause drug-induced GMA without systemic thrombotic microangiopathy, in which vascular endothelial growth factor-nuclear factor-κ B pathway could be involved. This is the first case of biopsy-proven bortezomib-induced GMA. If proteinuria (mainly albuminuria) increases after using bortezomib, GMA should be suspected as an adverse effect of bortezomib even absent of clinical signs of systemic thrombotic microangiopathy.

Over the past several years, a novel ultrasound imaging modality termed superb microvascular imaging (SMI) has enabled visualization of microvessels. SMI ultrasound studies of peripheral artery diseases have significantly extended our knowledge of tissue microcirculation and the arterial microenvironments of atherosclerotic lesions. We here present an overview of current knowledge on the utility of SMI assessment of vascular diseases and highlight certain peripheral microcirculation disorders for which SMI is particularly valuable. The evidence indicates that SMI can detect intraplaque neovascularization and usefully assess carotid plaque vulnerability; vascularization of the carotid arterial wall detected by SMI is a potential marker of disease activity in patients with Takayasu arteritis; SMI reveals the foot microcirculation and yields a quantitative vascular index (in line with the angiosome concept); and, SMI may serve as an auxiliary diagnostic modality for hereditary hemorrhagic telangiectasia and Raynaud syndrome. In general, microcirculatory evaluation by SMI is an attractive field for future research on therapeutic strategies for peripheral vascular diseases.

Transcatheter aortic valve implantation (TAVI) is a safe and effective alternative to surgical valve replacement in intermediate and even in low-risk patient cohorts. Direct aortic (DAo) route may be used in patients with severe peripheral vascular disease. Here, we present an 88-year old patient hospitalized with cardiogenic shock. Echocardiography revealed severe aortic valve stenosis with aortic valve area 0.5 cm², mean gradient of 55 mmHg, and peak gradient 92 mmHg. TAVI was considered by the Institutional Heart Team. Multislice computed tomography (MSCT) revealed severe peripheral vascular disease, decreased calibration of abdominal aorta, and multiple large vulnerable atherosclerotic plaques. The patient was scheduled for a DAo TAVI. A 26-mm Medtronic CoreValve Evolut R valve was implanted after predilatation with median sternotomy. The patient was discharged after 96 hours. Although transfemoral (TF) access is used as the default approach for TAVI, it was contraindicated in our patient owing to severe peripheral vascular disease and decreased calibration of the abdominal aorta at its narrowest point (4.5 mm) with multiple large vulnerable atherosclerotic plaques. Careful preprocedural MSCT evaluation is essential and directly affects the success of the procedure. MSCT is also mandatory to confirm the best cannulation zone that must be met for a successful DAo TAVI.

Transit time flow meter (TTFM) allows quick and accurate intraoperative graft assessment. The main study goal is to evaluate the influence of graft flow measurements on long-term clinical outcomes in patients with chronic limb-threatening ischemia (CLTI) undergoing bellow the knee (BTK) vein bypass surgery. Between January 1st, 1999 and January 1st, 2006, 976 CLTI consecutive patients underwent lower extremity bypass surgery. When applying the exclusion criteria, 249 patients were included in the final analysis. Control measurements were performed at the end of the procedure. Patients were divided according to the mean (more/less than 100 ml/min) and diastolic graft flow (more/less than 40 ml/min) values in four groups. The primary endpoints were a major adverse limb event (male) and primary graft patency. After the median follow-up of 68 months, a group with the mean graft flow below 100 ml/min and the diastolic graft flow below 40 ml/min had the highest rates of male (χ2 = 36.60, DF = 1, P

Background Popliteal artery injury is associated with a high risk of limb loss; identifying factors associated with increased morbidity and mortality is hampered by its rare occurrence and confounding factors. Anecdotal observations suggest delay in diagnosis of obese patients may be associated with amputation. We aimed to determine whether there is an increased risk of early amputation and if diagnosis is delayed in obese patients with popliteal artery injuries. Methods We conducted a retrospective cohort study using National Trauma Data Bank (NTDB) data from 2013 to 2017. We extracted those sustaining popliteal artery injury, assigning obesity class based on body mass index. We included select demographic and clinical variables, using time to imaging as a surrogate for time to diagnosis. Statistical models were used to calculate the impact of obesity on amputation rates and time to diagnosis. Results We identified 4803 popliteal artery injuries in the data set; 3289 met inclusion criteria. We calculated an 8.5% overall amputation rate, which was not significantly different between obese (N = 1305; 39.7%) and nonobese (N = 1984; 60.3%) patients. Statistical analysis identified peripheral vascular disease, diabetes, and smoking as risk factors for amputation. Time to imaging was similar for obese and nonobese patients. Conclusions and Relevance Analysis of NTDB data suggests that obesity is associated with neither increased early amputation rate nor longer time to imaging in patients with popliteal artery injury. However, our study suggests that underlying comorbidities of peripheral vascular disease and diabetes are associated with an increased risk for amputation in these patients.

BackgroundExposure to extremely or moderate low temperatures is associated with increased morbidity and mortality risk. Peripheral vascular disease (PVD) is a slow and progressive circulation disorder. Given that cold temperature causes constriction of the small arteries and veins in the skin, patients who suffer from peripheral circulation problems, like PVD, may be vulnerable to cold injuries. This study aimed to investigate the association between PVD and cold-induced injuries in the winter among Korean adults. We further analyzed the association stratified by body mass index (BMI) classification.MethodsWe used the 2002–2015 National Health Insurance Service-National Sample Cohort data and included a total of 535,186 adults as the study population. Patients with underlying PVD were identified by ICD-10 code I73. Cold-related illnesses were defined by ICD-10 codes (T690, T691, T698, T699, T330 ~ T339, T340 ~ T349, and T350 ~ T357). Body mass index (BMI) was categorized into underweight, normal weight, overweight, and obese.ResultsA total of 23.21% (n = 124,224) were PVD patients, and 0.59% (n = 3154) had cold-induced injuries. PVD patients were more likely to be diagnosed with cold injuries, but it was valid only in the underweight or normal weight groups. After adjusting for age, sex, income, cigarette smoking, alcohol consumption, regular exercise, high blood pressure, and hyperglycemia, PVD patients had a significantly increased odds ratio (OR) for cold injuries [adjusted OR = 1.11; 95% confidence intervals (95% CI): 1.01–1.21]. Increased OR for cold injuries in PVD patients was also observed in adults (adjusted OR = 1.14; 95% CI: 1.03–1.25 in Model 2), but not in the elderly. When we classified study subjects into the four BMI groups, the adjusted OR of cold injuries in PVD patients was significant in the underweight group (OR = 1.83; 95% CI, 1.26–2.66) and normal weight group (OR = 1.15; 95% CI, 1.03–1.27), not in those with overweight and obese. In adults, a consistent result was found in adults in the underweight group (OR = 1.63; 95% CI, 1.08–2.47 in Model 2) and normal weight group (OR = 1.19; 95% CI, 1.07–1.33 in Model 2). In the elderly, the adjusted OR for cold injuries was only significant in the underweight group (OR = 3.37; 95% CI, 1.08–10.53 in Model 2).ConclusionsWe found a significant association between PVD and cold-induced injuries in the general population. BMI modified the association. Thus, the association observed appears to be clinically applicable to PVD patients being low to normal BMI.

Objective Endovascular procedures are conventionally conducted using two dimensional fluoroscopy. A new technology platform, Fiber Optic RealShape (FORS), has recently been introduced allowing real time, three dimensional visualisation of endovascular devices using fiberoptic technology. It functions as an add on to conventional fluoroscopy and may facilitate endovascular procedures. This first in human study assessed the feasibility of FORS in clinical practice. Methods A prospective cohort feasibility study was performed between July and December 2018. Patients undergoing (regular or complex) endovascular aortic repair (EVAR) or endovascular peripheral lesion repair (EVPLR) were recruited. FORS guidance was used exclusively during navigational tasks such as target vessel catheterisation or crossing of stenotic lesions. Three types of FORS enabled devices were available: a flexible guidewire, a Cobra-2 catheter, and a Berenstein catheter. Devices were chosen at the physician's discretion and could comprise any combination of FORS and non-FORS devices. The primary study endpoint was technical success of the navigational tasks using FORS enabled devices. Secondary study endpoints were user experience and fluoroscopy time. Results The study enrolled 22 patients: 14 EVAR and eight EVPLR patients. Owing to a technical issue during start up, the FORS system could not be used in one EVAR. The remaining 21 procedures proceeded without device or technology related complications and involved 66 navigational tasks. In 60 tasks (90.9%), technical success was achieved using at least one FORS enabled device. Users rated FORS based image guidance “better than standard guidance” in 16 of 21 and “equal to standard guidance” in five of 21 procedures. Fluoroscopy time ranged from 0.0 to 52.2 min. Several tasks were completed without or with only minimal X-ray use. Conclusion Real time navigation using FORS technology is safe and feasible in abdominal and peripheral endovascular procedures. FORS has the potential to improve intra-operative image guidance. Comparative studies are needed to assess these benefits and potential radiation reduction.

Background: A direct comparison of severe acute respiratory syndrome coronavirus 2 positive patients with a severe acute respiratory syndrome coronavirus 2 negative control group undergoing an operative intervention during the current pandemic is lacking, and a reliable estimate of the assumed difference in morbidity and mortality between both patient categories remains unknown.Methods: We included all consecutive patients with a confirmed pre- or postoperative severe acute respiratory syndrome coronavirus 2 positive status (operated in 27 hospitals) and negative control patients (operated in 4 hospitals) undergoing emergency or elective operations. A propensity score-matched comparison of clinical outcomes was performed between severe acute respiratory syndrome coronavirus 2 positive and negative tested patients (control group). Primary outcome was overall 30-day mortality rate between both groups. Main secondary outcomes were overall, pulmonary, and thromboembolic complications.Results: In total, 161 severe acute respiratory syndrome coronavirus 2 positive and 342 control severe acute respiratory syndrome coronavirus 2 negative patients were included in this study. The 30-day overall postoperative mortality rate was greater in the severe acute respiratory syndrome coronavirus 2 positive cohort compared with the negative control group (16% vs 4% respectively; P = .007). After propensity score matching, the severe acute respiratory syndrome coronavirus 2 positive group consisted of 123 patients (median 70 years of age [interquartile range 59-77] and 55% male) were compared with 196 patients in the matched control group (median 69 years (interquartile range 58-75] and 53% male). The 30-day mortality rate and risk were greater in the severe acute respiratory syndrome coronavirus 2 positive group compared with the matched control group (12% vs 4%; P = .009 and odds ratio 3.4 [95% confidence interval 1.5-8.5]; P = .005, respectively). Overall, pulmonary and thromboembolic complications occurred more often in severe acute respiratory syndrome coronavirus 2 positive patients (P Conclusion: Patients diagnosed with perioperative severe acute respiratory syndrome coronavirus 2 have an increased risk of 30-day mortality, pulmonary complications, and thromboembolic events. These findings serve as an evidence-based argument to postpone elective surgery and selected emergency cases. (C) 2020 The Author(s). Published by Elsevier Inc.

Background and aims Patients with obesity are at high risk of suffering from arterial and venous peripheral vascular disease (PVD). Bariatric surgery is an effective strategy to achieve weight reduction for patients with obesity. The long-term impact of bariatric surgery on obesity-related morbidity is subject to increasing research interest. This study aimed to ascertain the impact of bariatric surgery on the long-term occurrence of PVD in patients with obesity. Methods The study population was extracted from the Clinical Practice Research Datalink, a nation-wide database containing primary and secondary care records of consenting patients. The intervention cohort was 2959 patients who had undergone bariatric surgery during follow-up; their controls were 2959 propensity-score-matched counterparts. The primary endpoint was development of any PVD: arterial or venous. Secondary endpoints were incident peripheral arterial disease alone, incident peripheral venous disease alone. Results Three hundred forty-six patients suffered a primary endpoint during follow-up. Bariatric surgery did not improve peripheral vascular disease rates as a whole, but it was associated with significantly lower event rates of arterial disease (HR = 0.560, 95%CI 0.327–0.959, p = 0.035) but higher event rates of venous disease (HR = 1.685, 95%CI 1.256–2.262, p < 0.001). Conclusions Bariatric surgery was associated with significantly reduced long-term occurrence of arterial disease but increased occurrence of venous disease in patients with obesity.