Objective: The objective of this study was to use non-invasive laser Doppler flowmeter to measure changes in blood flow in peripheral vessels in the legs before and after stress induced by leg elevation stress test and investigate correlations with the ankle-brachial pressure index (ABI). Methods: Subjects included 28 patients over 20 years of age (mean, 73 years) who reported chiefly of leg symptoms such as intermittent claudication, numbness, chills, or cramps had been examined at the study institution, and agreed to participate in the study. The ABI of both legs was measured, and patients were divided into two groups: low ABI (ABI ≤0.9) and normal ABI (ABI ≥0.9). Blood flow in the big toe was measured using a box-type laser Doppler flowmeter before, during, and after leg-elevation stress. Amplitude of the recorded waveform and changes in blood flow were compared. Results: Average ABI was 1.09 ± 0.10 in the normal ABI group (33 legs) and 0.68 ± 0.17 in the low ABI group (21 legs). Amplitude before and during stress was significantly smaller in the low ABI group than in the normal ABI group (p <0.01), and there was a significant correlation with ABI before and during stresses (r = 0.4606, r = 0.5048, respectively; p <0.05). Change in blood flow during stress was significantly lower in the low ABI group than in the normal ABI group (p <0.05). There was a significant correlation between change in blood flow during stress and ABI in both groups (r = 0.5073; p <0.05). There was also a significant correlation between change in blood flow and change in amplitude in both groups (r = 0.5477; p <0.05). Conclusion: Results of this study show, that comparing amplitude and change in blood flow before and after leg extension and elevation stress, there was a correlation between change in blood flow and amplitude, and ABI during stress. A box-type laser Doppler flowmeter may provide a means of screening for peripheral arterial disease.
Objective: To investigate the effectiveness of endovascular balloon angioplasty to preserve the patency of failing hemodialysis arteriovenous fistulas (AVF) and prosthetic arteriovenous grafts (AVG). Methods: Patients on hemodialysis who received endovascular intervention for access problems were retrospectively analyzed. Fistulography was performed on patients who were suspected to have access stenosis and balloon angioplasty performed in the same setting if a stenosis of ≥50% is detected. Patients were followed up for post-operative complications and access restenosis or failure. Results: 42 hemodialysis patients with 44 access sites (29 AVFs, 15 AVGs) required endovascular balloon angioplasty. There were no perioperative complications. Technical success rate was 100%. Median time from initial access creation to first balloon angioplasty was 13 months (2–146 months) for AVFs and 8 months (2–71 months) for AVGs. 19 of 44 patients subsequently developed restenosis. Median time for restenosis or access failure was 11 months (1–18 months) for AVFs and 5 months (1–10 months) for AVGs. Kaplan-Meier analysis for access patency after endovascular intervention showed 72% patency at 6 months and 32% at 12 months. Conclusions: Endovascular balloon angioplasty is effective in restoring patency of failing hemodialysis accesses. Recurrence is common, and repeat interventions are required.
Objectives: Atherosclerosis has been identified as a risk factor for both morbidity and mortality in patients undergoing coronary artery bypass grafting (CABG). To investigate outcomes following CABG for severe atherosclerosis, and to determine whether different surgical techniques can reduce the risk of neurologic events in these patients. Methods: We studied 225 consecutive patients who underwent elective isolated CABG. Routine preoperative and intraoperative examinations identified patients with severe atherosclerosis. We compared the outcomes between patients with (group A; 42 ceses) and those without (group N; 183 cases) severe atherosclerosis. Results: 36 patients (85.7%) in group A and 176 (96.2%) in group N underwent off-pump coronary artery bypass (OPCAB); 6 (14.3%) in group A and 7 (3.8%) in group N underwent on-pump beating CABG. Three patients in group A suffered deep sternal infection (7.1%), and one suffered stroke (2.4%) compared with none in group N. No cerebral infarction or neurologic events occurred in patients who underwent OPCAB (n = 212, 94.2%). Conclusions: Prevalence of complications was significantly greater among patients with severe atherosclerotic disease who underwent OPCAB than in those without atherosclerotic disease. Careful selection of surgical strategies can prevent perioperative stroke and reduce mortality.
Background: Coronary artery disease (CAD) is the leading cause of death worldwide, and the major cause of hospital admissions in the Western countries. The pathogenesis of CAD is closely related to nitric oxide release and formation. The purpose of this study was to investigate the status of platelets nitric oxide in patients with coronary artery disease. Methods: We measured platelets aggregation, cGMP, NO (nitrite/nitrate level), NO synthase activity, plasma NO, and ionized Ca2+ in 40 healthy volunteers and 120 patients with myocardial infarction, unstable and stable angina, with 40 subjects in each group. The subjects’ age mean range was from 40–51 years. Results: Platelets aggregation, NO, cGMP, NO synthase activity, plasma NO and ionized Ca2+ have increased significantly (P <0.001) across the patients groups compared to controls. Platelets NO synthase activity (mean ± SD / U / 109 platelets) in healthy controls, MI, unstable angina and stable angina patients were 1.19 ± 0.56, 1.21 ± 0.64, 1.64 ± 0.98 and 1.57 ± 0.81 respectively. The cGMP (mean ± SD / pmole / 109 platelets) levels were 0.95 ± 0.41, 1.53 ± 0.64, 3.18 ± 0.77, and 5.12 ± 1.5 respectively. Conclusions: The present study demonstrated that platelets aggregation, NO, cGMP, NO synthase activity, plasma NO, and ionized Ca2+ profoundly increased in CAD. The increases in NO-cGMP components may have resulted as a compensatory response to ameliorate platelet activity and Ca2+ levels in CAD patients.
Objective: To investigate ultrasonographic character of carotid plaques, and incidences of brain embolism in carotid angioplasty and stenting (CAS) and carotid endarterectomy (CEA). Materials and Methods: CEA (22/25 symptomatic lesions) and CAS (17/20 symptomatic lesions) between 2007 and 2010. Embolic protection devices (15 occlusion and 5 filtering devices) were used during CAS. Carotid plaques were classified into three categories (I: calcificated, II: intermediately echogenic, III: echolucent). Magnetic resonance imaging (MRI) was used to investigate brain emboli. Results: Ultrasonographic character of the plaques in CEA cases (I: 4%, II: 88%, III: 8%) was different from the one in CAS cases (I: 10%, II: 90%, III: 0%). The incidence of brain embolism in the CAS cases was 52.6 % while 0% in the CEA cases (p = 0.00037). CAS had high incidences of brain embolism in any plaques (I: 100%, II: 43.8%). In the most recent 9 procedures of CAS using occlusion devices, averaged number of embolic lesion was 1.0 (0 post operative day; 0 POD). The number increased as 1.4 (1 POD) and 2.0 (7 POD). Conclusion: CEA should be currently the first choice for most patients with a high-grade and symptomatic carotid artery stenosis.
Objective: The CHADS2 score is a stroke risk stratification scheme in patients with non-valvular atrial fibrillation (NVAF). The aim of this study was to determine whether the CHADS2 score can help to predict the risk of non-cerebral acute arterial embolism. Materials and Methods: One hundred and seventeen patients who underwent surgery for non-cerebral acute arterial embolism with NVAF between 1997 and 2009 were enrolled in the cross sectional study. The CHADS2 score of each patient was calculated at the onset of symptoms. The distribution of the CHADS2 score was compared with that of other studies analyzing patients with stroke. Results: The perioperative mortality was 11.1%. A comparison of patients with stroke revealed that our distribution curves were significantly shifted to the left, showing that the CHADS2 score did better in predicting stroke than non-cerebral embolism. On the other hand, the distribution in our series coincides with that of NVAF patients in general. These results indicated that the risk of non-cerebral embolism occurs at the same rate regardless of the CHADS2 score. Conclusions: The CHADS2 scoring system seems to be an unreliable predictor of non-cerebral embolism, and may not contribute in avoiding potentially life-threatening acute arterial occlusion of the peripheral artery.
Purpose: To determine the predictive value of serum lipid levels on the development of later cardiovascular events after abdominal aortic aneurysm (AAA) surgery. Methods: A total of 101 patients under 70 undergoing an elective AAA surgery were divided into the following two groups: 1) those who developed later cardiovascular events after AAA surgery, including cerebral infarction (n = 4), catheter intervention (PCI) or surgery for coronary artery disease (CAD) (n = 9) and other vascular disease. (CVE group; n = 19); 2) those without later events (NoCVE group: n = 82). Preoperative atherosclerotic risk factors including serum lipid levels were subjected to univariate and multivariate analysis. Results: The CVE group showed a significantly lower high-density lipoprotein cholesterol (HDL-C) level (32.9 ± 6.6 vs 41.6 ± 12.1 mg/dL; p <0.001), higher low-density lipoprotein cholesterol (LDL-C) / HDL-C ratio (4.30 ± 1.01 vs 3.24 ± 1.15; p = 0.001), and higher prevalence of mild CAD (without an indication of PCI) (p = 0.029) preoperatively. Cox hazard analysis indicated that preexistent mild CAD (hazard ratio 4.70) and preoperative HDL-C <35 mg/dL (hazard ratio 3.07) were significant predictors for later cardiovascular events after AAA surgery. Conclusion: Patients at high risk for later cardiovascular events should require a careful follow-up and may also require an aggressive lipid-modifying therapy.
Pulmonary embolism (PE) is one of the most undiagnosed causes of death, and more than half of fatal PE is discovered only during autopsy. The author reports a case of sudden death from massive pulmonary thromboembolism due to an inferior vena cava (IVC) thrombosis caused by chronic pancreatitis. An extensive search for the location of the thrombus identified the source of emboli. The probable mechanism of IVC thrombosis caused by chronic pancreatitis is discussed. Awareness of this serious complication of chronic pancreatitis may have prevented the sudden death.
We report the successful treatment of thoracoabdominal dissection, which extended into the left iliac artery, despite two independent complications: graft infection and a relatively rare, delayed postoperative paraplegia. The paraplegia suddenly occurred on postoperative day 10, and after an intravenous infusion of heparin and methylprednisolone, it gradually subsided. Moreover, graft infection was diagnosed on postoperative day 27, and with continuous irrigation of antibiotic treatment it was cured without recurrence of infection. Although anticoagulation therapy is not indicated for paraplegia, we suppose that it might be used as an adjunct therapeutic.
Here, we report a case of a 19-year-old man with acute myeloid leukemia complicated by deep vein thrombosis (DVT) in which we placed a retrievable inferior vena cava (IVC) filter during catheter directed thrombolysis (CDT). We were able to retrieve the IVC filter after a successful CDT and concluded that the use of this filter might be efficacious and better than an indwelling IVC filter that is associated with long-term risks. A retrievable filter and CDT should be considered in patients who are at transient risk for phlebemphraxis and require placement of a filter.
We present a case of an 80-year-old male who had a right buttock claudication after embolization of the right internal iliac artery and endovascular aneurysm repair (EVAR) for aneurysms of the right common iliac and abdominal arteries. We used follow-up dynamic computed tomography to measure the diameter of the superior gluteal artery (SGA). The comparison ratio (SGA diameter after EVAR / SGA diameter before EVAR) of the right SGA at 1, 3, and 9 months was 0.74, 0.80, and 1.1, respectively, while that of the left SGA at 9 months was 0.97. The patient reported using a walking stick at 1- and 3-month follow-ups but not at the 9-month follow-up. The computed tomography (CT) showed sequential dilatation of the SGA, which appeared to be associated with the relief of the buttock claudication.
An 80-year-old man presented with painful leg ulceration due to steal phenomenon from a groin arteriovenous fistula (AVF) 10 years following a coronary angiogram. The diagnosis of the AVF was confirmed by duplex examination of the groin vessels which demonstrated characteristic flow pattern in the femoral arterial and venous system. Angiography further confirmed the site of the fistulous communication and this was managed by a covered stent graft. We discuss the incidence of AVF, risk factors for its development, relevant diagnostic investigations and management options along with strategies to reduce the incidence of AVF following percutaneous punctures.
Fibromuscular dysplasia (FMD) is a nonatherosclerotic, non-inflammatory vascular disease that mainly affects the renal and internal carotid arteries. Involvement of other sites, including arteries of the extremities, is uncommon, and only a few histologically confirmed cases have been reported. FMD of the arteries of the extremities can result in ischemia requiring surgical or endovascular reconstruction. In the present report, two cases of FMD are described: one case of femoropopliteal artery occlusive disease, and one case of nonsymptomatic progression of external iliac artery dissection, both with histological confirmation of FMD. Clinical presentation, treatment, outcome and histological findings of previously reported cases are reviewed. FMD should be considered as a cause of occlusion, stenosis, dissection or aneurysm of the peripheral arteries: although rare, it can lead to limb-threatening ischemia or life-threatening aneurysm rupture.
We present two cases of arteriovenous fistulas associated with aneurysms of the infrarenal aorta or common iliac artery. A definitive diagnosis is sometimes difficult given the varied and unclear presentation. However, with the correct preoperative diagnosis, mortality can be reduced. Both cases, being reported here, were diagnosed preoperatively and underwent alternate surgical repairs. One case was treated by aortic exclusion, whereas the second case was treated by primary closure of the fistula. Repair techniques were chosen based on acuity of presentation. Given our experience with these two cases, we conclude that direct closure is possible but dependent on the chronicity of the lesion.
An 82-year-old man was admitted to our institution with a painful pulsating mass in the left groin. He had undergone bypass surgery with a bifurcated Cooley double velour knitted Dacron graft to treat aorto-iliac occlusive disease 21 years previously. Computed tomography demonstrated a 35-mm pseudoaneurysm near the distal anastomosis site of the graft. Opening the aneurysm revealed that the graft was disrupted along the guideline. We resected the aneurysm and interposed an expanded polytetrafluoroethylene (ePTFE) graft. Vascular surgeons should consider that grafts can fail in patients with long-term prosthetic grafts.
Pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) is still challenging. The outcome of patients with proximal pulmonary artery disease is generally better than that of a distal lesion. However, we experienced poor results in two difficult cases having predominant proximal lesions even after effective PEA. Both of them had a long-time history of CTEPH and preoperative condition was critical. Although relatively large amount of thickened intima with massive thrombi were extracted from the proximal pulmonary arteries, they required postoperative percutaneous cardiopulmonary support due to residual pulmonary hypertension. Both of them finally died from pulmonary bleeding and adult respiratory distress syndrome.
We presented a case of a completely occluded great saphenous vein and transient thrombocytosis following endovenous laser treatment (EVLT) for primary varicose veins of the lower extremity. A 54-year-old man with a left saphenous varicose vein underwent EVLT surgery. Twelve-watt laser irradiation was delivered over the length of 33 cm of the saphenous vein. The cumulative exposure was 1042 J. Nine days after treatment, the platelet count increased up to 610 × 103 /mm3 and returned to normal after 2 months. A complete occlusion of the great saphenous vein commonly occurs after EVLT, but no case of transient thrombocytosis has been reported.
Persistent sciatic artery is a relatively uncommon peripheral vascular malformation of the lower extremity arterial blood supply that is often misdiagnosed. We present a case report of a 52-year-old, obese female who presented to our center with symptoms of lower extremity ischemia. We describe a novel approach combining open and endovascular techniques for the treatment of a persistent sciatic artery aneurysm, providing maximal benefit, while minimizing potential complications due to her co-morbidities.