Factors influencing the prognosis of acute basilar artery occlusion patients treated endovascularly: the impact of treatment time window and preoperative symptoms

Objective

The aim of this study was to examine the factors influencing the prognosis of patients diagnosed with acute basilar artery occlusion (BAO) who receive endovascular treatment. Our particular emphasis was on the predictive implications of the time window for treatment (from symptom onset to femoral artery puncture) and preoperative symptoms for prognosis.

Methods

A retrospective analysis of data collected from 51 BAO patients who received endovascular treatment at the Neurosurgery Department of Jinhua Central Hospital from April 2018 to October 2021 was undertaken. The data included immediate post-interventional recanalization rates and the 90-day clinical prognoses of the patients. We used the Modified Rankin Scale (mRs) to categorize patients into two prognosis groups: a favorable prognosis group (mRs score ≤2) and an unfavorable prognosis group (mRs score >2). Preoperative symptoms were gauged using the Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS) scores. A logistic regression analysis was conducted to identify risk factors affecting the prognosis of BAO patients following endovascular treatment.

Results

The procedure resulted in complete recanalization in all patients (100%). However, four patients (7.8%) passed away during the postoperative hospitalization period. The remaining 47 patients were followed up for 3 months. It was found that 15 patients (31.91%) had a favorable prognosis, while 32 (68.09%) had an unfavorable prognosis. It was generally observed that patients with an unfavorable prognosis had notably higher preoperative GCS and NIHSS scores (p < 0.05). Logistic regression analysis revealed that preoperative symptom severity, as indicated by NIHSS score, and treatment time window were significant prognostic risk factors for patients undergoing endovascular treatment for BAO (p < 0.05).

Conclusion

Endovascular intervention for BAO appears to be safe and effective, with greater likelihood of a favorable prognosis in patients treated within ≤6 h. The chances of favorable prognosis could potentially be linked to the severity of the patient's preoperative symptoms.

Bacterial cellulose biomaterials for the treatment of lower limb ulcers

Chronic ulcers of the lower limbs are common and recurrent, especially in the elderly population, they are disabling injuries that generate a great socioeconomic burden. This scenario encourages the development of new, low-cost therapeutic alternatives. The present study aims to describe the use of bacterial cellulose in the treatment of lower limb ulcers. This is an integrative literature review, carried out in the PubMed and Science Direct databases by associating the descriptors, with the inclusion criteria being clinical studies in the last 5 years, available in full in English, Portuguese and Spanish. Five clinical trials were analyzed and the main therapeutic effects obtained in the experimental groups that used bacterial cellulose dressings were a reduction in the area of the wounds, one of the studies showed a reduction of 44.18cm2 in the area of the wound, the initial lesions measured on average 89.46cm2 and at the end of the follow-up, they had an average of 45.28cm2, since the reduction in pain and the decrease in the number of exchanges were advantages described in all groups that used the BS. It is concluded that BC dressings are an alternative for the treatment of lower limb ulcers, their use also reduces operational costs related to the treatment of ulcers.

Peripheral Arterial Disease and Prosthetic Joint Infection Resulting in Hip Disarticulation: A Case Report

Introduction

The aim of this study was to report a patient with refractory prosthetic joint infection (PJI) and severe peripheral arterial disease that necessitated hip disarticulation (HD), a rare and aggressive procedure. While this is not the first HD performed due to PJI, this is the first reported incidence that deals with profound infection burden along with immense vascular disease that has failed all other treatment options.

Case Report

We report a case of an elderly patient with a prior history of the left total hip arthroplasty, PJI, and severe peripheral arterial disease who underwent a rare HD procedure and was discharged with minimal complications. Before this major surgery, several surgical revisions and antibiotic regimens were attempted. The patient had also failed a revascularization procedure to treat an occlusion stemming from the peripheral arterial disease and had developed a necrotic wound at the surgical site. Irrigation and debridement of associated necrotic tissue was unsuccessful and due to concerns such as cellulitis, HD was performed with patient consent.

Conclusion

HD is a rare procedure that comprises only 1-3% of all lower limb amputations and is reserved for extremely deleterious indications such as infection, ischemia, and trauma. Complication and 5 year mortality rates have been reported to be as high as 60% and 55%, respectively. Despite these rates, the patient case illustrates a situation, in which early detection of indications for HD prevented further negative outcomes. Based on this case, we believe that HD is a reasonable treatment of choice in patients with severe peripheral arterial disease who fail revascularization and prior moderate treatment options. However, the limited availability of data involving HD and variety of comorbid conditions necessitate further analysis in terms of outcomes.

Morphological and Compositional Features of Chronic Internal Carotid Artery Occlusion in MR Vessel Wall Imaging Predict Successful Endovascular Recanalization

Background: We sought to determine if the morphological and compositional features of chronic internal carotid artery occlusion (CICAO), as assessed by MR vessel wall imaging (MR-VWI), initially predict successful endovascular recanalization. Methods: Consecutive patients with CICAO scheduled for endovascular recanalization were recruited. MR-VWI was performed within 1 week prior to surgery for evaluating the following features: proximal stump morphology, extent of occlusion, occlusion with collapse, arterial tortuosity, the presence of hyperintense signals (HIS) and calcification in the occluded C1 segment. Multivariate logistic regression was used to identify features associated with technical success and construct a prediction model. Results: Eighty-three patients were recruited, of which fifty-seven (68.7%) were recanalized successfully. The morphological and compositional characteristics of CICAO were associated with successful recanalization, including occlusions limited to C1 and extensive HIS, as well as the absence of extensive calcification, absence of high tortuosity, and absence of artery collapse. The MR CICAO score that comprised the five predictors showed a high predictive ability (area under the curve: 0.888, p < 0.001). Conclusion: the MR-VWI characteristics of CICAO predicted the technical success of endovascular recanalization and may be leveraged for identifying patients with a high probability of successful recanalization.

Contribution of Orbital Ultrasound to the Diagnosis of Central Retinal Artery Occlusion

We aimed to evaluate the diagnostic value of orbital ultrasound in the etiologic diagnosis of central retinal artery occlusion (CRAO). For this purpose, patients with CRAO evaluated at our center between 2011 and 2021 were reviewed. Demographic variables, vascular risk factors and ultrasound findings were collected. An orbital duplex was performed in all cases and complemented with other diagnostic explorations. We attended 36 cases of CRAO. In all patients, orbital ultrasound confirmed the diagnosis of CRAO: in 75% emboli material (spot sign) was observed in CRA and in 25% flow alteration in CRA without visible embolus. The positive spot sign (PSS) group differed from patients with negative spot sign (NSS) in terms of etiology: 8 PSS cases (29.6%) had a major cardioembolic cause, 4 (14.8%) a large vessel atheromatous disease, 15 (55.6%) an undetermined cause. Some 21 (77.8%) PSS patients had some minor cardioembolic cause, mainly calcifications of the left valves. In the NSS group, 2 (22%) were diagnosed with giant cell arteritis (GCA). In CRAO, the ultrasound spot sign could be a guide for the detection of embolic sources. Its absence makes it necessary to consider more strongly the possibility of arteritis. Furthermore, our findings suggest a key role of calcium embolism in PSS patients.

Angiographic patterns and temporal changes of arterial lesions in Behcet's disease

BACKGROUND

Behcet's disease (BD) can entail vascular involvement in various forms including aneurysm. We evaluated the angiographic patterns and changes in arterial lesions over time in BD patients with arterial involvement.

METHODS

We reviewed the medical records of BD patients diagnosed with arterial lesions between 1995 and 2018. Angiographic patterns were categorized as stenosis, occlusion, dilatation, or aneurysm. Patients were divided according to symptom duration (<5, 5-10, >10 years). Cox proportional-hazards model was used to evaluate the risk factors for vascular progression.

RESULTS

47 BD patients had arterial involvement in the following patterns: aneurysm (n = 31), stenosis (n = 17), dilatation (n = 13), and occlusion (n = 8). Aneurysm (70.8%) was the most common pattern in 24 patients with short (<5 years) symptom duration. Stenosis was more common (50.0%) in 12 patients with longer symptom durations (>10 years). In 23 patients with follow-up imaging (median, 5.7 years), eight (34.8%) developed 11 new lesions: stenosis (n = 5), dilatation (n = 1), and aneurysm (n = 5). One stenotic lesion progressed to occlusion, and two dilated lesions progressed to aneurysms. Lower extremity involvement and methotrexate use were associated with arterial progression, with hazard ratios of 5.716 (p = 0.029) and 0.101 (p = 0.049), respectively.

CONCLUSION

In BD patients with arterial involvement, aneurysm was the most common pattern in earlier stages of BD, while stenosis was more common in later stages of BD. Methotrexate use was associated with lower risk of arterial lesion progression.

Endovascular Therapy for Stroke due to Basilar Artery Occlusion: A BASIC Challenge at BEST

Basilar artery occlusion stroke is known to have poor outcome with a high rate of morbidity and mortality despite best medical therapy. Since the original report of intra-arterial therapy for basilar artery occlusion in 1983, two recent randomized trials comparing endovascular therapy versus best medical management were completed on a large scale, BASICS (Basilar Artery International Cooperation Study) and the BEST trial (Basilar Artery Occlusion Endovascular Intervention Versus Standard Medical Treatment), both of which demonstrated equivocal benefit of the two modalities. In this commentary, we comment and highlight important lessons related to basilar occlusion stroke as learned from the BASICS and BEST randomized trials.

Safety and Blood-Flow Outcomes for Hybrid Recanalization in Symptomatic Refractory Long-Segmental Vertebral Artery Occlusion-Results of a Pilot Study

Objective: Hybrid recanalization for vertebral artery (VA) long-segmental occlusion using a combination of ostial vertebral endarterectomy and distal endovascular stenting has achieved technical success. The safety and efficacy of the hybrid technique should be further evaluated.

Methods: We examined a cohort of refractory patients with long-segmental occlusion in the VA and low flow in the basilar artery (BA). The hybrid technique was performed to achieve the recanalization of VA. Angiograms were analyzed for occlusive length, contralateral VA status and collaterals. Clinical variables, including 30-days outcomes and blood-flow changes within 6 months based on quantitative magnetic resonance angiography (qMRA) with non-invasive optimal vessel analysis (NOVA), were collected pre- and post-operatively.

Results: Among 290 consecutive cases with VA initial segment stenosis or occlusion, 14 patients (13 male and 1 female) with symptomatic long-segmental VA occlusion and low flow in the BA were refractory to the best standard medical therapy. The hybrid technique was successful in obtaining recanalization in all but one patient. The mean follow-up period was 17.2 ± 9.2 months. One patient had new ischemic deficits within seven days of the operation. Four patients suffered from transient Horner syndrome postoperatively, but had recovered completely by the 6-months follow-up. Within this period, all revascularization was visible with computed tomography angiography (CTA), and the blood-flow in the BA improved significantly (66.4 ± 15.3 ml/min vs. 104.0±12.9 ml/min, P < 0.05) within 6 months. No ischemic events recurred during follow-up.

Conclusions: The hybrid technique is potentially a safe and feasible method to achieve recanalization and improve hemodynamic compromise for long-segmental VA occlusion.

Emergent carotid artery stenting in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion: Comparison of tandem intracranial occlusion and isolated cervical internal carotid artery occlusion

PURPOSE

Acute ischemic strokes caused by steno-occlusive lesion of the cervical internal carotid artery are associated with poor clinical outcome. We evaluated the clinical efficacy of emergent carotid artery stenting for the management of these lesions. We compared the clinical outcomes regarding the intracranial lesion, namely tandem occlusions versus isolated cervical internal carotid artery occlusion.

MATERIALS AND METHODS

We retrospectively reviewed patients with acute ischemic stroke who underwent carotid artery stenting for cervical internal carotid artery steno-occlusive lesion between 2011 and 2018. After dividing the patients into two groups according to the presence or absence of intracranial lesions (tandem group and isolated cervical group), we analyzed demographic data, angiographic findings, and clinical outcomes. A modified Rankin Scale score ≤2 was defined as a favorable clinical outcome.

RESULTS

Of 75 patients, 46 patients (61.3%) had tandem lesions, and the remaining 29 had only cervical internal carotid artery steno-occlusive lesion. Successful stenting was performed in all patients with favorable clinical outcomes (64.0%). Successful reperfusion score (thrombolysis in cerebral infarction ≥2 b) was 84.0%; tandem group (76.1%) versus isolated cervical group (96.6%) of cases. Mean modified Rankin Scale score at 90-days was 2.09. The rate of favorable clinical outcome showed no statistically significant difference between the two groups (p = 0.454).

CONCLUSIONS

Endovascular treatment in patients with acute ischemic stroke due to cervical internal carotid artery steno-occlusive lesion is a technically feasible and clinically effective intervention regardless of intracranial occlusion. Therefore, we recommend endovascular treatment regardless of the presence of concomitant intracranial artery occlusion for patients with acute ischemic stroke caused by cervical internal carotid artery steno-occlusive lesion.

Aortoiliac occlusive disease associated with an ectopic pelvic kidney

A pelvic kidney is a rare congenital anomaly. In patients requiring aortic surgery, the diagnosis of associated pelvic kidney is always challenging. This anomaly is best known for being associated with abdominal aortic aneurysm and rarely, with aortoiliac occlusive disease. We report the case of a 59-year-old man who presented with critical left lower limb ischemia secondary to bilateral iliac occlusion associated with pelvic kidney. He underwent aortofemoral bypass with an uneventful outcome.

Association of complete blood count parameters, d-dimer, and soluble P-selectin with risk of arterial thromboembolism in patients with cancer

BACKGROUND

Patients with cancer are at risk of developing arterial thromboembolism (ATE). With the prevalence of cancer and cardiovascular diseases on the rise, the identification of risk factors for ATE in patients with cancer is of emerging importance.

OBJECTIVES

As data on the association of potential biomarkers with risk of ATE in patients with cancer are scarce, we conducted a cohort study with the aim to identify blood-based biomarkers for ATE risk prediction in patients with cancer.

PATIENTS/METHODS

Overall, 1883 patients with newly diagnosed cancer or progressive disease after complete or partial remission were included and followed for 2 years. Venous blood was drawn at study inclusion for measurement of complete blood count parameters, total cholesterol, d-dimer, and soluble P-selectin (sP-selectin) levels.

RESULTS

The 2-year cumulative incidence of ATE was 2.5%. In univariable analysis, red cell distribution width (subdistribution hazard ratio (SHR) per doubling: 4.4, 95% CI: 1.4-14.1), leukocyte count (1.2, 1.1-1.5), neutrophil count (1.6, 1.1-2.3), and sP-selectin levels (1.9, 1.3-2.7) were associated with risk of ATE in patients with cancer; d-dimer was not associated with the risk of ATE (1.1, 0.9-1.4). After adjustment for age, sex, and smoking status the association prevailed for the neutrophil count (adjusted [adj.] SHR per doubling: 1.6, 1.1-2.4), and sP-selectin levels (1.8, 1.2-2.8).

CONCLUSIONS

An elevated absolute neutrophil count and higher sP-selectin levels were associated with an increased risk of ATE in patients with cancer. Their role for predicting cancer-related ATE needs to be validated in further studies.

Popliteal Artery Entrapment Syndrome: A Case Report and Review of the Literature

BACKGROUND Popliteal artery entrapment syndrome (PAES) results from an anomalous relationship between the popliteal artery and the myofascial structures of the popliteal fossa. The most common presenting symptoms include intermittent pain in the feet and calves on exercise, resulting in lameness. PAES can lead to popliteal artery thrombosis, stenosis, distal arterial thromboembolism, or arterial aneurysm. The treatment of PAES includes surgical exploration with fasciotomy, myotomy, or sectioning of fibrous band formation, to release the popliteal artery. However, in cases with thrombotic occlusion, thromboendarterectomy with venous patch arterioplasty, or venous graft arterial bypass surgery may be required. This report describes the presentation and surgical management of a case of PAES presenting with limb pain and includes a review of the literature on this condition. CASE REPORT A previously healthy 47-year-old woman presented with a 20-day history of sudden pain in the left lower limb, associated with pallor and a loss of arterial pulses below the knee. Angiography of the affected limb showed occlusion of the left supragenicular popliteal artery, with arterial occlusion, suggestive of arterial thrombus. Imaging of the right popliteal artery, which was not occluded, showed that it was medially deviated. An ipsilateral saphenous vein graft was used to bypass the left supragenicular popliteal artery to the infragenicular popliteal artery, resulting in resolution of the patient's symptoms. CONCLUSIONS PAES is rare and can be under-diagnosed, possibly due to lack of knowledge of this condition. However, if the diagnosis is made early, the prognosis is usually favorable, following appropriate surgical treatment.

Experience With the Absorb Everolimus-Eluting Bioresorbable Vascular Scaffold in Arteries Below the Knee: 12-Month Clinical and Imaging Outcomes

OBJECTIVES

The aim of this study was to investigate the midterm performance of an everolimus-eluting, bioresorbable vascular scaffold (Absorb, Abbott Vascular, Santa Clara, California) for the treatment of focal tibial and distal popliteal lesions.

BACKGROUND

Drug-eluting stents are used below the knee to improve technical success and durability, but the ongoing presence of a permanent metal scaffold may have deleterious effects on the local vessel.

METHODS

Tibial and distal popliteal angioplasty with scaffold placement was performed using an everolimus-eluting, bioresorbable scaffold (Absorb). Clinical and ultrasound follow-up was performed at 1, 3, 6, 12, and 24 months to detect binary restenosis and evaluate safety, restenosis, and clinical improvement.

RESULTS

Thirty-eight limbs in 33 patients were treated for critical limb ischemia (68.4%) or severe claudication (31.6%). Fifty scaffolds were used to treat a total of 43 lesions, with a mean length of 19.2 ± 11.6 mm. During a mean follow-up period of 12.0 ± 3.9 months, 5 patients died, and all others were available for follow-up. Among the 38 treated limbs, clinical improvement was present in 30 (79%). Binary restenosis was detected in 3 of 50 scaffolds (6%). Using the Kaplan-Meier method, rates of primary patency were 96% and 84.6% at 12 and 24 months, respectively, and rates of freedom from clinically driven target lesion revascularization were 96% and 96% at 12 and 24 months, respectively. Complete wound healing occurred in 64% of those treated for tissue loss, with no major amputation and a limb-salvage rate of 100%.

CONCLUSIONS

Twelve-month follow-up demonstrated excellent safety, patency, and freedom from target lesion revascularization using the Absorb bioresorbable vascular scaffold below the knee.

The Nellix™ EndoVascular sealing system in patients with abdominal aortic aneurysms in conjunction with iliac artery occlusive disease

Introduction Concomitant abdominal aortic aneurysm formation and aortoiliac occlusive disease is a challenging combination, often requiring open reconstructive surgery. In this study, we have assessed a single center experience of the Nellix EndoVascular Aneurysm Sealing System in the treatment of an abdominal aortic aneurysm in conjunction with iliac artery occlusive disease. Methods Retrospectively case files of patients treated with Nellix EndoVascular Aneurysm Sealing System in a single center were reviewed. The primary endpoints of the study were the technical success of Nellix EndoVascular Aneurysm Sealing System in patients with coincidental iliac artery occlusive disease and the successful exclusion of the aneurysm during follow-up. Results Of the 96 patients that were treated with Nellix EndoVascular Aneurysm Sealing System, five were identified that had an abdominal aortic aneurysm in conjunction with iliac artery occlusive disease. Treated patients had either unilateral (n = 4) or bilateral (n = 1) common iliac artery occlusive disease varying from 70% stenosis to complete occlusions. The lesion length varied from 5 to 50 mm and in two cases it involved an occluded bare metal stent. The indication for surgery was the abdominal aortic aneurysm in all patients, including three also suffering from claudication. In all patients the iliac artery occlusive disease was pretreated with balloon-expandable covered stents. Technical success was achieved in all five patients. After a median follow-up of nine months all stents were patent with no signs of endoleak and stable aneurysm diameters. All patients were free of intermittent claudication or ischemic wounds. Conclusion Nellix EndoVascular Aneurysm Sealing System seems feasible and safe in patients with a combination of abdominal aortic aneurysm and iliac artery occlusive disease.

Differential gene expression in human abdominal aortic aneurysm and aortic occlusive disease

Abdominal aortic aneurysm (AAA) and aortic occlusive disease (AOD) represent common causes of morbidity and mortality in elderly populations which were previously believed to have common aetiologies. The aim of this study was to assess the gene expression in human AAA and AOD. We performed microarrays using aortic specimen obtained from 20 patients with small AAAs (≤ 55mm), 29 patients with large AAAs (> 55mm), 9 AOD patients, and 10 control aortic specimens obtained from organ donors. Some differentially expressed genes were validated by quantitative-PCR (qRT-PCR)/immunohistochemistry. We identified 840 and 1,014 differentially expressed genes in small and large AAAs, respectively. Immune-related pathways including cytokine-cytokine receptor interaction and T-cell-receptor signalling were upregulated in both small and large AAAs. Examples of validated genes included CTLA4 (2.01-fold upregulated in small AAA, P = 0.002), NKTR (2.37-and 2.66-fold upregulated in small and large AAA with P = 0.041 and P = 0.015, respectively), and CD8A (2.57-fold upregulated in large AAA, P = 0.004). 1,765 differentially expressed genes were identified in AOD. Pathways upregulated in AOD included metabolic and oxidative phosphorylation categories. The UCP2 gene was downregulated in AOD (3.73-fold downregulated, validated P = 0.017). In conclusion, the AAA and AOD transcriptomes were very different suggesting that AAA and AOD have distinct pathogenic mechanisms.

Invasive evaluation of plaque morphology of symptomatic superficial femoral artery stenoses using combined near-infrared spectroscopy and intravascular ultrasound

The purpose of this study is to characterize the plaque morphology of severe stenoses in the superficial femoral artery (SFA) employing combined near-infrared spectroscopy and intravascular ultrasound (NIRS-IVUS). Atherosclerosis is the most common cause of symptomatic peripheral arterial disease. Plaque composition of SFA stenoses has been characterized as primarily fibrous or fibrocalcific by non-invasive and autopsy studies. NIRS has been validated to detect lipid-core plaque (LCP) in the coronary circulation. We imaged severe SFA stenoses with NIRS-IVUS prior to revascularization in 31 patients (46 stenoses) with Rutherford claudication ⩾ class 3. Angiographic parameters included lesion location and stenosis severity. IVUS parameters included plaque burden and presence of calcium. NIRS images were analyzed for LCP and maximum lipid-core burden index in a 4-mm length of artery (maxLCBI4mm). By angiography, 38 (82.6%) lesions were calcified and 9 (19.6%) were chronic total occlusions. Baseline stenosis severity and lesion length were 86.0 ± 11.0% and 36.5 ± 46.5 mm, respectively. NIRS-IVUS identified calcium in 45 (97.8%) lesions and LCP in 17 (37.0%) lesions. MaxLCBI4mm was 433 ± 244. All lesions with LCP also contained calcium; there were no non-calcified lesions with LCP. In conclusion, this is the first study of combined NIRS-IVUS in patients with PAD. NIRS-IVUS demonstrates that nearly all patients with symptomatic severe SFA disease have fibrocalcific plaque, and one-third of such lesions contain LCP. These findings contrast with those in patients with acute coronary syndromes, and may have implications regarding the pathophysiology of atherosclerosis in different vascular beds.

Can contrast-enhanced ultrasound with second-generation contrast agents replace computed tomography angiography for distinguishing between occlusion and pseudo-occlusion of the internal carotid artery?

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of contrast-enhanced ultrasound with a second-generation contrast agent in distinguishing between occlusion and pseudo-occlusion of the cervical internal carotid artery, comparing it with that of conventional Doppler ultrasound and the gold standard, computed tomography angiography.

METHOD

Between June 2006 and June 2012, we screened 72 symptomatic vascular surgery outpatients at a public hospital. Among those patients, 78 cervical internal carotid arteries were previously classified as occluded by Doppler ultrasound (without contrast). The patients were examined again with Doppler ultrasound, as well as with contrast-enhanced ultrasound and computed tomography angiography. The diagnosis was based on the presence or absence of flow.

RESULTS

Among the 78 cervical internal carotid arteries identified as occluded by Doppler ultrasound, occlusion was confirmed by computed tomography angiography in only 57 (73.1%), compared with 59 (77.5%) for which occlusion was confirmed by contrast-enhanced ultrasound (p>0.5 vs. computed tomography angiography). Comparing contrast-enhanced ultrasound with Doppler ultrasound, we found that the proportion of cervical internal carotid arteries classified as occluded was 24.4% higher when the latter was used (p<0.001).

CONCLUSIONS

We conclude that, in making the differential diagnosis between occlusion and pseudo-occlusion of the cervical internal carotid artery, contrast-enhanced ultrasound with a second-generation contrast agent is significantly more effective than conventional Doppler ultrasound and is equally as effective as the gold standard (computed tomography angiography). Our findings suggest that contrast-enhanced ultrasound could replace computed tomography angiography in this regard.

Rapid onset of peripheral artery disease in a chronic myeloid leukemia patient without prior arterial disorder: direct relationship with nilotinib exposure and clinical outcome

The second-generation tyrosine kinase inhibitor (TKI) of the BCR-ABL1 oncoprotein nilotinib used in patients with chronic myeloid leukemia is suspected to increase the risk of arterial occlusion, especially in patients with pre-existing cardiovascular risk factors or established cardiovascular diseases. Here, we describe a case of unexpected and rapid onset of symptomatic peripheral artery disease (PAD) associated with silent stenosis of digestive and renal arteries in a nilotinib-treated patient devoid of significant cardiovascular diseases (CVD) risk factor, prior atherosclerotic disease, or other cause of arterial damage. This is the first report to establish a direct relationship between nilotinib exposure and PAD and to reveal that arterial damage is irreversible despite rapid drug withdrawal. However, functional outcome was favorable upon rapid TKI replacement, specific cardiovascular disease management, and development of collateral arterial network.

Progressive vascular damage may lead to bladder underactivity in rats

PURPOSE

We assessed whether progressive vascular damage causes bladder underactivity in rats.

MATERIALS AND METHODS

Adult male Sprague Dawley® rats were divided into 4 groups. Controls received a regular diet and tap water. The L-NAME group received a 2% cholesterol diet and L-NAME (3 mg/ml) dissolved in drinking water. The arterial injury group underwent balloon endothelial injury of the common iliac arteries and received a 2% cholesterol diet and tap water after injury. The arterial injury/L-NAME group also received L-NAME dissolved in drinking water. At 8 weeks urodynamics were performed, bladder tissue was harvested for pharmacological studies, and the iliac arteries and bladders were histologically examined.

RESULTS

Iliac arteries from the injury and injury/L-NAME groups showed neointimal formation and luminal occlusion but arteries from the L-NAME group did not. In the L-NAME and injury groups bladder capacity and voided volume were less than in controls. Conversely, in the injury/L-NAME group these cystometric parameters were significantly greater than in the other groups. Post-void residual volume in the injury/L-NAME group tended to increase compared with the other groups. Contractile responses of bladder strips to various stimuli in the L-NAME, injury and injury/L-NAME groups were significantly less than in controls and the lowest in the injury/L-NAME group. The injury and injury/L-NAME groups showed a significantly increased percent of collagen compared to controls.

CONCLUSIONS

Pelvic arterial occlusive disease plus vascular endothelial dysfunction may cause progressive vascular damage resulting in bladder dysfunction that develops from bladder hyperactivity to bladder underactivity.

Medical management of critical limb ischaemia: where do we stand today?

Critical limb ischaemia (CLI) is a severe form of peripheral arterial disease (PAD). CLI often causes disabling symptoms of pain and can lead to loss of the affected limb. It is also associated with increased risk of myocardial infarction, stroke and death from cardiovascular disease. The aims of management in patients with CLI are to relieve ischaemic pain, heal ulcers, prevent limb loss, improve function and quality of life and prolong survival. Here, current evidence regarding the medical management of CLI is reviewed. Cardiovascular risk factors should be assessed in all patients with CLI; smoking cessation and treatment of hypertension, hyperlipidaemia and diabetes all reduce the mortality rate in those with PAD. Antiplatelet agents (either aspirin or clopidogrel) are recommended to reduce both the incidence of cardiovascular events and risk of arterial occlusion. By contrast, routine use of anticoagulation (either warfarin or heparin) is not recommended. Treatment of the limbs themselves is often more challenging. Prostanoids may have some efficacy for treating rest pain and for ulcer healing, and iloprost shows favourable results in reducing the risk of major amputations, but long-term follow-up data regarding disease progression are lacking. There is insufficient evidence to support the use of naftidrofuryl or cilostazol, and pentoxifylline is not beneficial. Furthermore, there is no evidence of proven benefit of hyperbaric oxygen. A number of angiogenic growth factors have been studied in Phase I studies and randomized controlled trials (RCTs). They appear to be safe, but efficacy results have been mixed. Treatment with stem cells also shows some potential from early trials, but further larger RCTs are needed to demonstrate clear benefit. Thrombolysis may be an alternative for patients who develop acute limb ischaemia and are unsuitable for surgical intervention. However, newer endovascular techniques are likely to have a greater role in the future.

Takayasu arteritis with coronary aneurysms causing acute myocardial infarction in a young man

Takayasu arteritis is an inflammatory condition that involves the large cardiac vessels, predominantly the aorta and its main branches. It typically affects young women (age, ≤40 yr), most often Asians and Latin Americans. Herein, we describe a rare manifestation of Takayasu arteritis in a 19-year-old black Tunisian man who presented with acute inferior myocardial infarction and complete atrioventricular block after occlusion from a giant aneurysm in the right coronary artery. The coronary artery disease was associated with aneurysmal dilations in the carotid, vertebral, and right renal arteries. Medical therapy improved Thrombolysis in Myocardial Infarction flow in the area of the giant aneurysm from grade 1 to grade 3. Upon the diagnosis of Takayasu arteritis, intravenous methylprednisolone and oral prednisone therapy was started. After 10 days of hospitalization, the patient was discharged on a medical regimen. Renovascular hypertension due to renal artery stenosis was suspected, so he underwent successful percutaneous transluminal angioplasty of the inferior segmental artery of the right renal artery. During 12 months of close postprocedural monitoring, he experienced lower blood pressure, no chest pain, and no cardiovascular complications.This association of conditions has not been previously reported. Besides presenting this very rare combination of findings, we discuss the differential diagnosis of Takayasu arteritis in our patient.

Balloon dilation and stenting of hypoplastic pulmonary arteries: a new area of cooperation between interventional pediatric cardiologists and cardiac surgeons

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Extracranial carotid artery. Current concepts of diagnosis and management

Extracranial carotid artery disease is a frequent cause of transient ischemic attack (about 50%), but a much less common cause of cerebral infarction (about 15%). Transient ischemic attack almost invariably precedes strokes caused by extracranial carotid stenosis, but rarely heralds strokes that result from cardiogenic embolism or intracranial vascular disease. When extracranial carotid stenosis produces a transient ischemic attack or stroke, artery-to-artery embolism is the predominant mechanism. Asymptomatic significant (>50%) carotid stenosis poses special clinical questions in patients scheduled to undergo general surgical or major cardiovascular operations. With general surgical procedures, there is no increased risk of stroke. With cardiovascular operations, however, there may be an increased risk of stroke in patients with critical (>90%) carotid stenosis or occlusion. When perioperative stroke occurs, the most common cause is embolism rather than focal hemodynamic change. For symptomatic high-grade (>70%) extracranial carotid stenosis, carotid endarterectomy is the treatment of choice in patients who are not high-risk surgical candidates. Alternatively, for high-risk patients, new drugs such as ticlopidine appear quite promising, and percutaneous angioplasty may also prove effective. Prevention of stroke must continue to be a major goal of national medical policy. Because cigarette smoking is the most important risk factor for extracranial carotid disease, more strenuous efforts must be directed toward eliminating this health risk.

Complications of laser-assisted angioplasty: definition and classification of perforations

Although laser-assisted angioplasty is becoming increasingly common, there has been no definitive report, drawing its data from a significant patient population, regarding the complications of this technique. To define and enumerate such adverse results, we collected data on 664 peripheral laser procedures performed in 349 patients over a 15-month period (February 1987 through April 1988). The complications proved similar to those of standard angioplasty: hematoma formation, 100 cases (15.0%); perforation/dissection, 38 cases (5.7%); acute thrombosis, 23 cases (3.5%); false aneurysm formation at the puncture site, 7 cases (1.1%); vascular spasm, 5 cases (0.8%); and embolism, 1 case (0.2%). Because perforation was the most significant complication during angioplasty, we devised a system for uniform documentation and reporting of perforations, based on both the arterial condition responsible for the laser probe's deviation and the clinical consequences of the aberration. According to this system, Class-I perforations are dissections that do not penetrate the adventitia; Class-II perforations are adventitial wall ruptures (true perforations) that do not require treatment; and Class-III perforations are adventitial wall ruptures with hemorrhage. In our series, we had no Class-III perforation, but had 21 Class-I (3.1%) and 17 Class-II (2.6%) perforations. Because prudent treatment of an evolving complication often can salvage the procedure, we discuss appropriate therapies, as well as preventive measures.

System design considerations for laser angioplasty

Laser angioplasty, or the use of laser radiation to vaporize or remove obstructure atherosclerotic plaque, has been an active area of research for the past several years. This article reviews current design considerations for developing a safe, effective clinical laser angioplasty system. The choice of laser, fiber, and catheter determines the performance characteristics of such a system. The laser provides the power source for ablative radiation, the fiber furnishes a means of transmitting the laser radiation, and the catheter provides a way of directing the fiber at the target tissue. Other considerations, such as the need for feedback control of laser ablation and the planned application of the system in the coronary or peripheral circulation, also determine the ultimate design.

Intraoperative angioscopically monitored laser-assisted angioplasty in treating lower-extremity atherosclerotic occlusive disease

As part of an ongoing multi-institutional study, our surgical center offered laser-assisted angioplasty to patients with significant, documented lower-extremity atherosclerotic occlusive disease, as an alternative to standard femoral-popliteal or femoral-tibial bypass. During the 1st 12 months of the study (September 1987 through August 1988), 31 patients had laser-assisted angioplasty in 34 limbs. The procedures were performed with an argon-powered laser probe that features a heated metallic tip and a window that furnishes 20% of the laser energy as a direct argon laser beam. Angioscopic monitoring was provided in each case. The immediate recanalization rate was 82% (28 of 34 limbs). After a follow-up period of 6 to 18 months (mean, 14 months), the patients continue to show clinical improvement of pretreatment symptoms, and noninvasive studies continue to reveal improved segmental arterial pressures. On the basis of this experience, we conclude that angioscopically monitored laser-assisted angioplasty has a role in the management of lower-extremity atherosclerotic occlusive disease.

Experimental background preceding direct laser-assisted angioplasty in the human coronary anatomy

The central question that faces coronary laser investigators is whether interaction between laser energy and target tissues can be controlled in a dynamic in vivo environment. In considering this question, the author reviews the in vitro and in vivo experiments that his center carried out before it began using laser angioplasty for clinical coronary applications. The in vitro experiments were undertaken to enable coaxial delivery of argon laser energy; to monitor the fluorescence of the lens assembly; to determine the effect of a saline infusion on the conduction of thermal energy; to evaluate the potential risk posed by embolization of debris; and to analyze the effects of increased beam divergence. The in vivo experiments were undertaken to examine the results of coaxial alignment of the laser beam in a rabbit model and to test the complete delivery system in dogs. The author also discusses his institution's 1st clinical trials of laser angioplasty in peripheral arteries, and its initial use of the laser technique in human coronary vessels.

Percutaneous laser-assisted balloon angioplasty of lower-extremity arterial disease in a free-standing laboratory: clinical experience with 100 cases

From September 1987 through May 1988, 86 patients (62 men and 24 women) underwent percutaneous laser-assisted balloon angioplasty, and 2 patients (1 man and 1 woman) underwent laser-assisted balloon angioplasty via cutdowns, in our free-standing catheterization laboratory. The patients' ages ranged from 36 to 81 years. One hundred limbs were treated; each had at least 1 total occlusion, and many had multiple significant occlusions (greater than 50%). Vascular access was attained via the common femoral artery in 62 limbs, via the popliteal artery in 34 limbs, and via a posterior tibial artery cutdown in 4 limbs. In all, 232 lesions were treated either by percutaneous laser-assisted balloon angioplasty (172 lesions) or by balloon angioplasty alone (60 lesions). Technical success was defined as "recanalization and dilation of the occluded arterial segment, resulting in a recognizable improvement in pulse that persisted until hospital discharge." The technical success/attempt ratios for the 172 laser-assisted treatments were as follows: iliac artery, 11/17 (64.7%); common femoral artery, 8/9 (88.9%); superficial femoral artery, 62/80 (77.5%); popliteal artery, 25/30 (83.3%); peroneal artery, 14/16 (87.5%); anterior tibial artery, 6/7 (85.7%); and posterior tibial artery, 9/13 (69.2%). Technical failure occurred in 25 limbs. Failure was not related to sex, age, approach artery, or diabetes, but it was related to the indication of impending limb loss (p < 0.01), previous vascular surgery (p < 0.01), amputation (p < 0.01), and lesion length of 20 cm or greater. Clinical success was defined as "clinical improvement in symptoms, with persistence of an improved pulse at follow-up." Recurrence was observed in 10 limbs. Recurrence was not related to sex, age, approach artery, diabetes, or lesion length, but it was related to the indication of impending limb loss (p < 0.05); to the fact that the patient was a cigarette smoker at the time of the procedure (p < 0.02); and (inversely) to the number of tibial vessels that remained patent post-intervention. Five patients required emergency surgery after laser-assisted angioplasty, but no limb amputation has been necessary. Minor complications included perforation (16 cases), hematoma formation (6 cases), dissection (3 cases), hemorrhage (1 case), hives (1 case), and fracture of the laser probe (1 case). We conclude that percutaneous laser-assisted balloon angioplasty can be safely accomplished in a free-standing laboratory and that the procedure is reasonably successful in patients with totally occluded lower-extremity arteries.

Hot-tip laser angioplasty: a review of the Texas Heart Institute experience

At the Texas Heart Institute, from October 1986 to October 1988, laser thermal angioplasty was used in conjunction with balloon angioplasty for treatment of 201 atherosclerotic vascular lesions in 162 patients. All patients had significant symptoms or impending limb loss. Most of the occlusions (148) were located in the superficial femoral artery; the clinical success rate in those cases was 80%. Similar success rates were noted in 25 iliac occlusions (77%) and 16 popliteal occlusions (88%). A small number of tibial vessels were also reopened successfully. Analysis of the results showed a correlation between success rates and lesion length. The success rate dropped from 79% for occlusions that were 10 cm and shorter, to 56% for occlusions ranging from 11 to 20 cm, and to 55% for occlusions longer than 20 cm. The incidence of perforations in most laser series is reflective of operator experience. Perforations occurred in 19 of 90 vessels (21%) in the 1st year of our experience and in 3 of 111 vessels (2.7%) in the 2nd year. Other complications included groin hematomas in 2 patients and embolization to the trifurcation vessels in 4. One patient died 8 hours after the procedure of complications unrelated to laser angioplasty. The safety and efficacy of "hot-tip" laser recanalization in the peripheral vasculature have been proved in early clinical experience. Some preliminary investigations have shown that laser-probe applications may be feasible in the coronary vasculature as well. Future applications of laser systems will depend on their proven ability to reduce restenosis rates and to reliably recanalize totally occluded vessels.

Anterior compartment exposure of the distal peroneal artery for bypass grafting

Occasionally, the distal peroneal artery is the only graftable below-the-knee vessel available for limb salvage; in such cases, surgical exposure of this artery can pose a major technical difficulty. The following article describes a simple, satisfactory method of exposure via the anterior compartment that does not necessitate the removal or fracture of a bone.