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Berchiolli R, Bertagna G, Adami D, Piaggesi A, Iacopi E, Giangreco F, Torri L, Troisi N. Peripheral Interventional Strategy Assessment (PISA) for Diabetic Foot Ulcer Revascularization: Preliminary Outcomes of a Multidisciplinary Pilot Study. Diagnostics (Basel) 2023; 13:2879. [PMID: 37761246 PMCID: PMC10528535 DOI: 10.3390/diagnostics13182879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/28/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Digital subtraction angiography (DSA) still represents the gold standard for anatomical arterial mapping and revascularization decision-making in patients with chronic limb-threatening ischemia (CLTI), although DUS (Doppler Ultrasound) remains a primary non-invasive examination tool. The Global Vascular Guidelines established the importance of preoperative arterial mapping to guarantee an adequate in-line flow to the foot. The aim of this study was to evaluate the accuracy of DUS in guiding therapeutic vascular treatments on the basis of Global Vascular Guidelines without the need of a second-level examination. METHODS Between January 2022 and June 2022, all consecutive patients with CLTI to be revascularized underwent clinical examination and DUS without further diagnostic examinations. Primary outcomes assessed were technical success, and 30-day mortality. Secondary outcomes were 1-year amputation free survival, and time between evaluation and revascularization. RESULTS Sixty-eight patients with a mean age of 73.6 ± 8.5 years underwent lower limb revascularization. Technical success was 100%, and the 30-day mortality rate was 2.9%. Mean time between evaluation and revascularization was 29 ± 17 days. One-year amputation free survival was 97.1%. CONCLUSIONS DUS without further diagnostic examinations can accurately assess the status of the vascular tree and foot runoff, providing enough information about target vessels to guide revascularization strategies.
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Affiliation(s)
- Raffaella Berchiolli
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (G.B.); (D.A.); (L.T.)
| | - Giulia Bertagna
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (G.B.); (D.A.); (L.T.)
| | - Daniele Adami
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (G.B.); (D.A.); (L.T.)
| | - Alberto Piaggesi
- Diabetic Foot Section, Department of Medicine, University of Pisa, 56126 Pisa, Italy; (A.P.); (E.I.); (F.G.)
| | - Elisabetta Iacopi
- Diabetic Foot Section, Department of Medicine, University of Pisa, 56126 Pisa, Italy; (A.P.); (E.I.); (F.G.)
| | - Francesco Giangreco
- Diabetic Foot Section, Department of Medicine, University of Pisa, 56126 Pisa, Italy; (A.P.); (E.I.); (F.G.)
| | - Lorenzo Torri
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (G.B.); (D.A.); (L.T.)
| | - Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (R.B.); (G.B.); (D.A.); (L.T.)
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Bhusal K, Kadel PB, Bhandari K, Aryal S, Gyawali N, Kushwaha A, Shrestha KR, Shrestha A. Popliteal artery thrombosis as a rare complication of paroxysmal nocturnal hemoglobinuria (PNH): A case report. Int J Surg Case Rep 2021; 87:106445. [PMID: 34607268 PMCID: PMC8497847 DOI: 10.1016/j.ijscr.2021.106445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/21/2021] [Accepted: 09/21/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction and importance Popliteal artery thrombosis a rare but life-threatening complication of Paroxysmal Nocturnal Hemoglobinuria caused due to hemolysis. Complications of further thrombotic event are common after initial management. Case presentation A 38 years old male, known case of PNH for 2 years, presented with the history of loss of pain sensation, coldness and loss of movement in left lower leg for 5 days and history of multiple blood transfusion. The patient underwent knee amputation because of possible complication of PNH. Clinical discussion Intermittent claudication along with paresthesia, lower extremity weakness, stiffness, and cool extremities are seen in patients of Peripheral Artery Disease. Ultrasound color duplex is a sensitive and specific examination for peripheral flow while gold standard techniques like MRI and CT angiogram to detect and diagnose arterial lesions. Conclusion The risk of thrombo-embolism in a patient of PNH should be considered by a treating doctor while early imaging and management should be done to reduce the complications and risk of amputation. Popliteal artery thrombosis is a rare life-threatening complication of Paroxysmal nocturnal hemoglobinuria (PNH) We report a known case of PNH patient diagnosed with acute occlusion of Popliteal artery due to thrombosis. Complications of further thrombotic event are common after initial management and subsequent above knee amputation was done.
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Affiliation(s)
- Kiran Bhusal
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal.
| | - Prashiddha B Kadel
- Manmohan Cardiothoracic Vascular and Transplant Center, Tribhuvan University, Kathmandu, Nepal
| | | | - Shova Aryal
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Nitin Gyawali
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Ashok Kushwaha
- Maharajgunj Medical Campus, Institute of Medicine, Kathmandu, Nepal
| | - Kajan Raj Shrestha
- Manmohan Cardiothoracic Vascular and Transplant Center, Tribhuvan University, Kathmandu, Nepal
| | - Anjan Shrestha
- Department of Hemato-Oncology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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Martinelli O, Alunno A, Jabbour J, Cuozzo S, Gattuso R. Duplex Ultrasound as a reliable alternative to CT angiography for treatment planning of Peripheral Artery Disease. INT ANGIOL 2021; 40:306-314. [PMID: 33832186 DOI: 10.23736/s0392-9590.21.04524-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The aim of this work is to compare the diagnostic accuracy of Duplex ultrasound (DUS) and CT angiography (CTA) in the study of arterial vessels, in patients with chronic peripheral arterial disease (PAD) of the lower limbs to undergo endovascular revascularization with the use of intraprocedural digital angiography (DSA). METHODS 94 patients with obstructive pathology of the arterial axes of the lower limbs were enrolled in the study. In all patients, endovascular revascularization treatment was considered the most suitable therapeutic choice. For this reason, ultrasound and CTA was performed preoperatively in all and based on the data obtained it was decided to classify the arterial tree into five segments: iliac, common femoral, superficial femoral, popliteal and infra-geniculate. According to the degree of stenosis or occlusion, the arteries were scored in no stenotic, stenotic and occluded. The comparison of the data provided by the DUS and the CTA was carried out with reference to the parameters obtained by the DSA. RESULTS The results of our experience have shown that in the iliac arterial district DUS proved to be less accurate than CT angiography when compared to DSA (Cohen's Kappa agreement of 0.91 and 1.0, respectively). Good diagnostic concordance were found in the femoro-popliteal district (Cohen's Kappa agreement 33 between 0.96 and 0.93). On the contrary, when the data of the infra-geniculate area were compared, CT angiography showed a net deficiency compared to DSA and DUS (Cohen's k: 0.75). CONCLUSIONS Due to its accuracy, high-quality DUS performed by well-trained operators may therefore represent a good alternative to CTA in patients undergoing endovascular revascularization, in order to reduce the use of contrast-enhanced radiological imaging especially when a condition of intolerance to the contrast medium and/or renal insufficiency coexists.
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Affiliation(s)
- Ombretta Martinelli
- Vascular Surgery Department, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Alessia Alunno
- Vascular Surgery Department, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy -
| | - Jihad Jabbour
- Vascular Surgery Department, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Simone Cuozzo
- Vascular Surgery Department, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Roberto Gattuso
- Vascular Surgery Department, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
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4
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Marco M, Valentina I, Daniele M, Valerio DR, Andrea P, Roberto G, Laura G, Luigi U. Peripheral Arterial Disease in Persons with Diabetic Foot Ulceration: a Current Comprehensive Overview. Curr Diabetes Rev 2021; 17:474-485. [PMID: 33023453 DOI: 10.2174/1573399816999201001203111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 11/22/2022]
Abstract
In developed countries, the prevalence of persons with diabetes and peripheral arterial disease (PAD) is approximately 50%. The presence of PAD is associated with non-healing ulcers, major amputation, cardiovascular morbidity, and mortality. It is estimated that persons with diabetes, foot ulceration and PAD have 50% of 5-years mortality rate. Therefore, subjects with ischemic diabetic foot ulcers (DFUs) should be considered a special group of patients with specific clinical characteristics, general health status and prognosis. In persons with ischemic DFUs, an early diagnosis and treatment are mandatory to reduce the risk of worse outcomes such as major amputation. Revascularization of occluded lower extremity arteries is the main treatment to restore blood flow in the foot and promote wound healing. Nonetheless, there are several unmet needs in the management of diabetic subjects with PAD and foot ulceration as medical therapy, diagnostic criteria and indications for revascularization, revascularization strategy and technical approach as well as the management of no-option critical limb ischemia patients. It is a common opinion that there is an evolution of PAD features in diabetic persons, which seems to present a more aggressive pattern. This may be related to the frequent presence of concomitant comorbidities such as renal failure which could influence the characteristics of atherosclerotic plaques and their distribution. The aim of this review is to commence a complete overview and state of the art in the treatment of patients with diabetes, PAD, and foot ulceration and to describe the current challenges and future perspectives.
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Affiliation(s)
- Meloni Marco
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Izzo Valentina
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Morosetti Daniele
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Da Ros Valerio
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Panunzi Andrea
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Gandini Roberto
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Giurato Laura
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Uccioli Luigi
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
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5
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Martinelli O, Alunno A, Drudi FM, Malaj A, Irace L. Duplex ultrasound versus CT angiography for the treatment planning of lower-limb arterial disease. J Ultrasound 2020; 24:471-479. [PMID: 33165702 DOI: 10.1007/s40477-020-00534-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/17/2020] [Indexed: 12/17/2022] Open
Abstract
PURPOSE This study aimed to assess the diagnostic accuracy of duplex sonography (DUS) compared with that of computed tomography angiography (CTA) in detecting occlusion and stenosis in peripheral arterial disease (PAD) in candidate patients for endovascular revascularization with intraprocedural digital subtraction angiography (DSA). METHODS The study involved 94 patients suffering from PAD who were candidates for endovascular procedures requiring DSA. They were all submitted preoperatively to DUS and CTA. Based on image analysis, five segments of the arterial tree were assessed: iliac, common femoral, superficial femoral, popliteal, and infrageniculate. According to the stenosis or occlusion degree, the arteries were rated as nonstenotic, stenotic, and occluded. RESULTS The agreement between DUS and CTA findings using DSA as a reference modality was expressed as a Cohen's kappa (κ) statistic agreement. Our results show that DUS has been less accurate than CTA in evaluating iliac arterial diseases (Cohen's κ agreement of 0.91 and 1.0, respectively) when measured against DSA. We found good diagnostic concordance between DUS and DSA in detecting hemodynamic stenosis and occlusion of the femoro-popliteal axis (Cohen's κ agreement between 0.96 and 0.93). Below the knee, CTA showed even less concordance with DSA (Cohen's κ 0.75). CONCLUSIONS Because of its accuracy, high-quality DUS performed by well-trained operators may therefore represent a good alternative to CTA in patients undergoing endovascular revascularization to minimize the use of contrast-enhanced radiological imaging. Nevertheless, preoperative CTA imaging is required in cases of nondiagnostic DUS or when a more complete overview of the vascular tree is needed for complex invasive interventions.
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Affiliation(s)
- Ombretta Martinelli
- Vascular Surgery Department, Policlinico Umberto I, "Sapienza" University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Alessia Alunno
- Vascular Surgery Department, Policlinico Umberto I, "Sapienza" University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Francesco Maria Drudi
- Radiology Department, Policlinico Umberto I, "Sapienza" University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Alban Malaj
- American Hospital of Tirana, Tirana, Albania
| | - Luigi Irace
- Vascular Surgery Department, Policlinico Umberto I, "Sapienza" University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
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6
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Pieruzzi L, Napoli V, Goretti C, Adami D, Iacopi E, Cicorelli A, Piaggesi A. Ultrasound in the Modern Management of the Diabetic Foot Syndrome: A Multipurpose Versatile Toolkit. INT J LOW EXTR WOUND 2020; 19:315-333. [PMID: 32820699 DOI: 10.1177/1534734620948351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Ultrasound (US) is a noninvasive and versatile technology that in recent years found acceptance in almost all the medical specialties, with diagnostic and interventional applications. In the diabetic foot syndrome (DFS), US found specific indications mainly in the screening, quantification, and follow-up of the vascular component of the pathology, but also in the study of the deformities and structural modifications induced by neuropathy and in the diagnosis and surgical management of infections, especially those that induce anatomical changes, like abscesses and fasciitis. This review will summarize all these application of US, giving special attention to the vascular aspects, and on the predominant role that US gained in recent times to guide the indication to revascularization, on the new standardized approach to the study of the arterial tree of the limb and the foot, the so-called duplex ultrasound arterial mapping, which significantly increased the utilization of US to plan the revascularizations in this complex pathology. Outside the vascular fields, the diagnosis of neuropathy and infection and the intraoperative use of US in the surgical management of abscesses and fasciitis will be discussed, leaving the last part to the new and interesting applications of US in the management of DFU, a field that is still in evolution, offering new possibilities to the health care professionals involved in the management of these chronic wounds. The variety of applications both in diagnostic and operative fields makes US a rather versatile technology-a toolkit-that should have a special place among those at reach of the specialists of DFS care.
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7
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Abstract
Ultrasound (US) and Doppler are often the first imaging to be carried out for arterial disease, and with good reason. US is noninvasive, free of radiation exposure and crucial for follow up imaging. The review that follows aims to highlight the various applications of US in imaging of the arterial system.
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Affiliation(s)
- Prashant Gupta
- Department of Radiology, Scunthorpe General Hospital, Northern Lincolnshire and Goole NHS Foundation Trust, UK
| | - Shannon Lyons
- Division of Cardiovascular Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sandeep Hedgire
- Division of Cardiovascular Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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8
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Uccioli L, Meloni M, Izzo V, Giurato L, Merolla S, Gandini R. Critical limb ischemia: current challenges and future prospects. Vasc Health Risk Manag 2018; 14:63-74. [PMID: 29731636 PMCID: PMC5927064 DOI: 10.2147/vhrm.s125065] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Critical limb ischemia (CLI) is considered the most severe pattern of peripheral artery disease. It is defined by the presence of chronic ischemic rest pain, ulceration or gangrene attributable to the occlusion of peripheral arterial vessels. It is associated with a high risk of major amputation, cardiovascular events and death. In this review, we presented a complete overview about physiopathology, diagnosis and holistic management of CLI. Revascularization is the first-line treatment, but several challenging cases are not treatable by conventional techniques. Unconventional techniques for the treatment of complex below-the-knee arterial disease are described. Furthermore, the state-of-the-art on gene and cell therapy for the treatment of no-option patients is reported.
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Affiliation(s)
| | | | | | | | - Stefano Merolla
- Department of Interventional Radiology, Università di Tor Vergata Roma, Rome, Italy
| | - Roberto Gandini
- Department of Interventional Radiology, Università di Tor Vergata Roma, Rome, Italy
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9
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Neufang A. Indikationen und Ergebnisse der Bypasschirurgie bei kritischer Extremitätenischämie (CLI). GEFASSCHIRURGIE 2015. [DOI: 10.1007/s00772-015-0024-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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Aiello A, Anichini R, Brocco E, Caravaggi C, Chiavetta A, Cioni R, Da Ros R, De Feo ME, Ferraresi R, Florio F, Gargiulo M, Galzerano G, Gandini R, Giurato L, Graziani L, Mancini L, Manzi M, Modugno P, Setacci C, Uccioli L. Treatment of peripheral arterial disease in diabetes: a consensus of the Italian Societies of Diabetes (SID, AMD), Radiology (SIRM) and Vascular Endovascular Surgery (SICVE). Nutr Metab Cardiovasc Dis 2014; 24:355-369. [PMID: 24486336 DOI: 10.1016/j.numecd.2013.12.007] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 10/31/2013] [Accepted: 12/01/2013] [Indexed: 02/07/2023]
Abstract
Diabetic foot (DF) is a chronic and highly disabling complication of diabetes. The prevalence of peripheral arterial disease (PAD) is high in diabetic patients and, associated or not with peripheral neuropathy (PN), can be found in 50% of cases of DF. It is worth pointing out that the number of major amputations in diabetic patients is still very high. Many PAD diabetic patients are not revascularised due to lack of technical expertise or, even worse, negative beliefs because of poor experience. This despite the progress obtained in the techniques of distal revascularisation that nowadays allow to reopen distal arteries of the leg and foot. Italy has one of the lowest prevalence rates of major amputations in Europe, and has a long tradition in the field of limb salvage by means of an aggressive approach in debridement, antibiotic therapy and distal revascularisation. Therefore, we believe it is appropriate to produce a consensus document concerning the treatment of PAD and limb salvage in diabetic patients, based on the Italian experience in this field, to share with the scientific community.
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Affiliation(s)
- A Aiello
- P.O. Campobasso - ASReM, Campobasso, Italy
| | - R Anichini
- Servizi di Diabetologia, USL 3, Pistoia, Italy
| | - E Brocco
- Policlinico Abano Terme, Presidio Ospedaliero ULSS 16, Veneto, Italy
| | - C Caravaggi
- Istituto Clinico "Città Studi", Milan, Italy
| | | | - R Cioni
- Dipartimento Radiologia Diagnostica, interventistica e medicina nucleare, Azienda Ospedaliera Universitaria Pisana, Pisa, italy
| | - R Da Ros
- Centro Diabetologico Monfalcone (GO) - Ass2, Gorizia, Italy
| | - M E De Feo
- U.O.S. Diabetologia A.O.R.N. "A. Cardarelli", Naples, Italy
| | - R Ferraresi
- Emodinamica Interventistica Cardiovascolare, Istituto Clinico Città Studi, Milan, Italy
| | - F Florio
- IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - M Gargiulo
- Chirurgia Vascolare, Azienda Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - G Galzerano
- Department of Surgery Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy
| | - R Gandini
- Dipartimento Diagnostica per immagini, Imaging molecolare, radioterapia e radiologia interventistica, Policlinico Universitario Tor Vergata, Rome, Italy
| | - L Giurato
- Diabetic Foot Unit, Dept of Internal Medicine, Policlinico Universitario Tor Vergata, Rome, Italy
| | - L Graziani
- Unità Operativa di Cardiologia Invasiva, Istituto Clinico "Città di Brescia", Brescia, Italy
| | - L Mancini
- Istituto Dermatologico Immacolata IRCCS, Rome, Italy
| | - M Manzi
- Radiologia Interventistica, Policlinico Abano Terme, Presidio Ospedaliero ULSS 16, Veneto, Italy
| | - P Modugno
- Dipartimento Malattie Cardiovascolari Fondazione Giovanni Paolo II, Università Cattolica Sacro Cuore, Campobasso, Italy
| | - C Setacci
- Department of Surgery Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy
| | - L Uccioli
- Diabetic Foot Unit, Dept of Internal Medicine, Policlinico Universitario Tor Vergata, Rome, Italy.
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Sun Z. Coronary CT angiography: Beyond morphological stenosis analysis. World J Cardiol 2013; 5:444-452. [PMID: 24392188 PMCID: PMC3879698 DOI: 10.4330/wjc.v5.i12.444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 10/04/2013] [Accepted: 11/19/2013] [Indexed: 02/06/2023] Open
Abstract
Rapid technological developments in computed tomography (CT) imaging technique have made coronary CT angiography an attractive imaging tool in the detection of coronary artery disease. Despite visualization of excellent anatomical details of the coronary lumen changes, coronary CT angiography does not provide hemodynamic changes caused by presence of plaques. Computational fluid dynamics (CFD) is a widely used method in the mechanical engineering field to solve complex problems through analysing fluid flow, heat transfer and associated phenomena by using computer simulations. In recent years, CFD is increasingly used in biomedical research due to high performance hardware and software. CFD techniques have been used to study cardiovascular hemodynamics through simulation tools to assist in predicting the behaviour of circulatory blood flow inside the human body. Blood flow plays a key role in the localization and progression of coronary artery disease. CFD simulation based on 3D luminal reconstructions can be used to analyse the local flow fields and flow profiling due to changes of vascular geometry, thus, identifying risk factors for development of coronary artery disease. The purpose of this article is to provide an overview of the coronary CT-derived CFD applications in coronary artery disease.
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12
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Wong TH, Tay KH, Sebastian MG, Tan SG. Duplex ultrasonography arteriography as first-line investigation for peripheral vascular disease. Singapore Med J 2013; 54:271-4. [DOI: 10.11622/smedj.2013107] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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13
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Guía de práctica clíníca de la ESC sobre diagnóstico y tratamiento de las enfermedades arteriales periféricas. Rev Esp Cardiol 2012. [DOI: 10.1016/j.recesp.2011.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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14
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Peng H, Schlaich EM, Row S, Andreadis ST, Swartz DD. A novel ovine ex vivo arteriovenous shunt model to test vascular implantability. Cells Tissues Organs 2011; 195:108-21. [PMID: 22005667 DOI: 10.1159/000331415] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The major objective of successful development of tissue-engineered vascular grafts is long-term in vivo patency. Optimization of matrix, cell source, surface modifications, and physical preconditioning are all elements of attaining a compatible, durable, and functional vascular construct. In vitro model systems are inadequate to test elements of thrombogenicity and vascular dynamic functional properties while in vivo implantation is complicated, labor-intensive, and cost-ineffective. We proposed an ex vivo ovine arteriovenous shunt model in which we can test the patency and physical properties of vascular grafts under physiologic conditions. The pressure, flow rate, and vascular diameter were monitored in real-time in order to evaluate the pulse wave velocity, augmentation index, and dynamic elastic modulus, all indicators of graft stiffness. Carotid arteries, jugular veins, and small intestinal submucosa-based grafts were tested. SIS grafts demonstrated physical properties between those of carotid arteries and jugular veins. Anticoagulation properties of grafts were assessed via scanning electron microscopy imaging, en face immunostaining, and histology. Luminal seeding with endothelial cells greatly decreased the attachment of thrombotic components. This model is also suture free, allowing for multiple samples to be stably processed within one animal. This tunable (pressure, flow, shear) ex vivo shunt model can be used to optimize the implantability and long-term patency of tissue-engineered vascular constructs.
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Affiliation(s)
- Haofan Peng
- Department of Chemical and Biological Engineering, Women and Children's Hospital of Buffalo, N.Y., USA
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15
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Tendera M, Aboyans V, Bartelink ML, Baumgartner I, Clément D, Collet JP, Cremonesi A, De Carlo M, Erbel R, Fowkes FGR, Heras M, Kownator S, Minar E, Ostergren J, Poldermans D, Riambau V, Roffi M, Röther J, Sievert H, van Sambeek M, Zeller T. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:2851-906. [PMID: 21873417 DOI: 10.1093/eurheartj/ehr211] [Citation(s) in RCA: 1035] [Impact Index Per Article: 79.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
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- 3rd Division of Cardiology, Medical University of Silesia, Ziolowa 47, 40-635 Katowice, Poland.
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16
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Bueno A, Acín F, Cañibano C, Fernandez-Casado JL, Castillo E. Diagnostic accuracy of contrast-enhanced magnetic resonance angiography and duplex ultrasound in patients with peripheral vascular disease. Vasc Endovascular Surg 2010; 44:576-85. [PMID: 20675318 DOI: 10.1177/1538574410377018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Noninvasive techniques such as duplex ultrasound (DU) and contrast-enhanced magnetic resonance angiography (CE-MRA) are valid alternatives in the preoperative evaluation of such patients. Our aim is to assess the diagnostic accuracy of CE-MRA and DU in patients with peripheral arterial disease (PAD). METHODS Forty consecutive patients underwent DU, hybrid CE-MRA, and digital subtraction angiography (DSA). Magnetic resonance angiography and DSA images were evaluated independently and in a blinded fashion. Every segment was graded as normal, stenosed less than 50%, stenosed more than 50%, or occluded. RESULTS There were 1720 segments for analysis. Duplex ultrasound depicting stenosis >50% demonstrated a sensitivity (S) 81.4%, specificity (E) 99%, positive predictive value (PPV) 96.2%, and negative predictive value (NPV) 94.8%. Occlusions showed S 90%, E 97%, PPV 98.1%, and NPV 88.4%. Magnetic resonance angiography depicting stenosis >50% demonstrated a S 91%, E 99%, PPV 96.7%, and NPV 97.6%. Occlusions showed S 95.4%, E 98%, PPV 98.4%, and NPV 94.7%. CONCLUSION Combined CE-MRA and DU is the first diagnostic approach in the preoperative assessment of PAD, leading to the use of DSA for selected cases.
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Affiliation(s)
- Alicia Bueno
- Vascular Surgery Department, Hospital Universitario de Getafe, Madrid, Spain.
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Ascher E, Hingorani A, Marks N. Duplex-guided balloon angioplasty of failing or nonmaturing arterio-venous fistulae for hemodialysis: A new office-based procedure. J Vasc Surg 2009; 50:594-9. [DOI: 10.1016/j.jvs.2009.03.061] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2009] [Revised: 03/26/2009] [Accepted: 03/28/2009] [Indexed: 11/30/2022]
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Fontcuberta J, Flores A, Orgaz A, Doblas M, Gil J, Leal I, Rodriguez R, Benito JM, Bermúdez MD. Reliability of preoperative duplex scanning in designing a therapeutic strategy for chronic lower limb ischemia. Ann Vasc Surg 2009; 23:577-82. [PMID: 19540712 DOI: 10.1016/j.avsg.2008.07.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Revised: 06/17/2008] [Accepted: 07/26/2008] [Indexed: 11/18/2022]
Abstract
The objective of this study was to compare the treatment plan designed on the basis of preoperative duplex scanning evaluation of the critical limb ischemia with the treatment plan finally carried out, after assessing the findings obtained during surgical or endovascular treatment. Over a period of 51 months a preoperative duplex scanning study was carried out in 335 consecutive patients with chronic critical ischemia, to design the best therapeutic strategy. Agreement between both plans were as follows: 80%, 82,7% and 59% in the examinations of the iliac arteries, femoropopliteal or tibial arteries respectively. The operation plan was more frequently modified due to a duplex scanning failure in procedures involving the the distal vessels(10 of 44 [22.7%], p < 0.01). In conclusion, duplex scanning evaluation of patients with occlusive arterial disease of the lower limbs permits the design of both a medical and a surgical or endovascular treatment plan with a high level of agreement with the findings obtained during the revascularization procedure.
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Affiliation(s)
- Juan Fontcuberta
- Hospital Virgen de la Salud, Cirugia Vascular y Endovascular, Toledo, Spain.
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Ascher E, Hingorani AP, Marks N, Puggioni A, Shiferson A, Tran V, Jacob T. Predictive factors of femoropopliteal patency after suboptimal duplex-guided balloon angioplasty and stenting: is recoil a bad sign? Vascular 2009; 16:263-8. [PMID: 19238867 DOI: 10.2310/6670.2008.00091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Currently, the value of stenting during femoropopliteal balloon angioplasty (FPBA) remains unclear. Herein we evaluate the patency rates of successful duplex-guided balloon angioplasty (DAGBA) alone versus suboptimal DAGBA followed by stenting and the prestenting dissection versus recoil as potential indicators of stent success or failure. Over a period of 27 months, we performed 291 duplex-guided FPBAs (194 stenoses; 97 occlusions) on 244 limbs in 220 patients. Disabling claudication was the indication in 67%. Critical limb ischemia was the indication in the remaining 33%. Self-expanding nitinol stents were used when plaque dissection and/ or recoil caused diameter reduction > or = 40%. Serial follow-up duplex scans were obtained. Severe restenosis (> 70%) was measured by B-mode imaging and a peak systolic velocity ratio > 3. Follow-up ranged from 1 to 41 months (mean 10 +/- 8.3 months). The overall mean interval for restenosis and occlusion was 6.5 +/- 4.2 months and 5.6 +/- 6.1 months, respectively. Stents did affect overall patency results compared with not using stents. Reasons for stenting were plaque recoil, dissection, or both in 98 (53%), 44 (24%), and 42 (23%) cases, respectively. Six-month patency was 59%, 94%, and 69%, respectively. The difference between plaque recoil and dissection was significant (p<.04). The use of stents during FPBA may be associated with balloon angioplasty site failure in the femoropopliteal segment. To our knowledge, this is the first report ever to document plaque recoil as a predictor of balloon angioplasty site failure notwithstanding stent placement.
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Affiliation(s)
- Enrico Ascher
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY 11219, USA.
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20
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Fernández-Samos R. Angiosomas y cirugía vascular. ANGIOLOGIA 2009. [DOI: 10.1016/s0003-3170(09)15003-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Hingorani AP, Ascher E, Marks N, Puggioni A, Shiferson A, Tran V, Jacob T. Limitations of and Lessons Learned from Clinical Experience of 1,020 Duplex Arteriography. Vascular 2008; 16:147-53. [DOI: 10.2310/6670.2008.00014] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective: Due to the inherent risks, deficiencies and cost associated with contrast arteriography (CA), our group has been utitilizing duplex arteriography (DA) for evaluating the arteries of the lower extremity for patients undergoing lower extremity revascularization. In an effort to further explore the strengths and weaknesses of DA, we reviewed our evolving experience with DA from January 1, 1998, to January 1, 2005. Patients and Methods: The arterial segments starting from mid-abdominal aorta to the pedal arteries were studied in cross-sectional and longitudinal planes using a variety of scanheads of 7–4, 10–5, 12–5, 5–2 and 3–2 MHz extended operative frequency range to obtain high-quality B-mode, color and power Doppler images as well as velocity spectra. In 906 patients, 1,020 duplex arteriograms were obtained. The ages ranged from 30–98 years old with a mean of 73±11 (SD) years. Fifty percent of the patients were diabetics. Indications for the examination included: tissue loss (409), rest pain (221), claudication (310), acute ischemia (74), popliteal aneurysm (45), SFA aneurysm (2), abdominal aortic aneurysms (AAA) (10) and failing bypass (55). Prior procedures had been performed in 262. DA was performed by six technologists (4 of whom are MDs). In all, 207 DA were performed intraoperatively and the remainder, preoperatively. Results: The resultant procedures based upon DA included: bypass to the popliteal artery (262) and bypass to an infrapopliteal artery (325), endovascular procedures (363), thrombectomy (11), embolectomy (9), inflow bypass procedures to the femoral arteries (46), débridment (4), amputation (8) and no intervention (75). The areas not visualized well included: iliac (73), femoral (26), popliteal (17), and infrapopliteal (221). Additional imaging after DA was deemed necessary in 102 cases to obtain enough information to plan lower extremity revascularization. Factors associated with increased need to obtain CA included: DM ( p<.001), infrapopliteal calcification ( p<.001), older age ( p = .01) and limb threatening ischemia ( p<.001). Factors not associated with the need to obtain CA included: which technologist performed the exam, whether the technologist has a medical degree and whether the patient underwent prior revascularization. Conclusions: In 90% of patients reviewed, DA is able to obtain the needed information to plan lower extremity revascularization. Severe tibial vessel calcification is the most common cause of an incomplete DA exam and determines when alternative imaging modalities need to be obtained.
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Affiliation(s)
- Anil P. Hingorani
- *Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Enrico Ascher
- *Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Natalie Marks
- *Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | | | | | - Victor Tran
- *Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Theresa Jacob
- *Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
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