RESUMEN
BACKGROUND AND AIM: The toe skin temperature in vascular patients can be low, making reliable toe pressure measurements difficult to obtain. The aim of this study was to evaluate the effect of heating on the toe pressure measurements. MATERIALS AND METHODS: A total of 86 legs were examined. Brachial pressure and toe pressure were measured at rest in a supine position using a laser Doppler device that also measured skin temperature. After heating the toes for 5 min with a heating pad, we re-measured the toe pressure. Furthermore, after heating the skin to 40° with the probe, toe pressures were measured a third time. RESULTS: The mean toe skin temperature at the baseline measurement was 24.0 °C (standard deviation: 2.8). After heating the toes for 5 min with a warm heating pad, the skin temperature rose to a mean 27.8 °C (standard deviation: 2.8; p = 0.000). The mean toe pressure rose from 58.5 (standard deviation: 32) to 62 (standard deviation: 32) mmHg (p = 0.029). Furthermore, after the skin was heated up to 40 °C with the probe, the mean toe pressure in the third measurement was 71 (standard deviation: 34) mmHg (p = 0.000). The response to the heating varied greatly between the patients after the first heating-from -34 mmHg (toe pressure decreased from 74 to 40 mmHg) to +91 mmHg. When the toes were heated to 40 °C, the change in to toe pressure from the baseline varied between -28 and +103 mmHg. CONCLUSION: Our data indicate that there is a different response to the heating in different clinical situations and in patients with a different comorbidity.
Asunto(s)
Índice Tobillo Braquial/métodos , Calor/uso terapéutico , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/terapia , Adulto , Comorbilidad , Femenino , Hospitales Universitarios , Humanos , Masculino , Persona de Mediana Edad , Posicionamiento del Paciente , Pletismografía/métodos , Pronóstico , Muestreo , Índice de Severidad de la Enfermedad , Posición Supina , Resultado del TratamientoRESUMEN
INTRODUCTION: As the population ages and the incidence of diabetes increases, the expected number of patients with critical limb ischaemia (CLI) requiring distal revascularization will remain high or even increase. The aim of this study was to investigate the long-term results of inframalleolar bypass. MATERIAL AND METHODS: A total of 352 inframalleolar bypasses for CLI performed between 2002 and 2013 were included. Risk factors were evaluated and patency (both clinical and imaging based), leg salvage, survival, and amputation free survival (AFS) assessed. RESULTS: The median follow up was 30 months (mean 42 months, range 1-186 months). The median age of the study population was 73 years, and 67% of the patients were male. The incidence of diabetes was 69%. In the majority of cases (82%), the indication for bypass was an ulcer or gangrene, and the remaining 18% of the patients had rest pain. Primary, assisted primary, and secondary clinical patency was 71.2%, 76.5%, 81.0%, and 59.7%, 69.3%, and 70.7%, and 49.0%, 58.6%, and 68.4% at 1, 5, and 10 years, respectively. The last imaging based secondary patency at 1, 5, and 10 years was 79.3%, 68.1%, and 62.8%, respectively. The popliteal artery as the inflow artery (n = 194) was associated with superior primary (p = .013), assisted primary (p = .028), and secondary patency (p = .014) when compared with bypasses originating from the femoral artery (n = 158). The leg salvage rate at 1, 5, and 10 years was 78.6%, 72.0%, and 67.2%, respectively. Leg salvage was equal in patients with and without diabetes (p = .460). The respective survival and AFS rates at 1, 5, and 10 years were 70.3%, 37.4%, and 15.9%, and 58.4%, 29.8%, and 12.8%. CONCLUSION: Bypass to the foot arteries yielded excellent long-term patency, and good limb salvage can be achieved in both non-diabetic and diabetic patients.
Asunto(s)
Implantación de Prótesis Vascular , Isquemia/cirugía , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/cirugía , Venas/trasplante , Adulto , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Implantación de Prótesis Vascular/efectos adversos , Comorbilidad , Enfermedad Crítica , Diabetes Mellitus/epidemiología , Supervivencia sin Enfermedad , Femenino , Finlandia , Hospitales Universitarios , Humanos , Incidencia , Isquemia/diagnóstico , Isquemia/fisiopatología , Estimación de Kaplan-Meier , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/epidemiología , Enfermedad Arterial Periférica/fisiopatología , Modelos de Riesgos Proporcionales , Recurrencia , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE/BACKGROUND: Owing to the increased life expectancy of the population the number of very old patients referred to vascular surgical units has increased. Advanced age is a well known risk factor in patients undergoing surgical interventions for lower limb ischemia. However, amputation performed on an elderly person living independently will lead to permanent institutional care. The aim of this study was to evaluate the outcome of patients aged 90 years and older with lower limb ischemia undergoing surgical or endovascular revascularization. METHODS: Two hundred and thirty-three nonagenarians with either chronic critical limb ischemia (CLI) or acute limb ischemia (ALI) who underwent revascularization at the authors' institution between 2002 and 2013 were included in this retrospective study. Risk factors were evaluated and survival, limb salvage, and amputation free survival (AFS) assessed. RESULTS: The median age of the study population was 92 years (range 90-100 years). The majority (81.1%) of the patients were female. One in four (24.5%) patients had diabetes, and the incidence of coronary artery disease was 79.8%. Seventy-three percent of the patients had CLI and 27% of had ALI. Seventy percent of the patients underwent surgical revascularization and 30% were treated endovascularly. The majority (72.5%) of the patients maintained their independent living status; 27.5% ended up in institutional care post-operatively. Similarly, the majority (82.0%) of the patients maintained their walking ability, while 18% were not able to ambulate independently after revascularization. One year survival, limb salvage, and AFS rates were 50.9% versus 48.6% (p = .505), 85.1% versus 87.0% (p = .259), and 45.7% versus 44.4% (p = .309) in the surgical versus endovascular group, respectively. Dementia was an independent risk factor of poor AFS (odds ratio: 1.56; 95% confidence interval: 1.077-2.272; p = .019). CONCLUSION: Good limb salvage can be achieved by both surgical and endovascular revascularization, and independent living can be maintained in the majority of the patients. However, the benefit of revascularization is limited owing to high mortality, especially in patients with dementia.
Asunto(s)
Isquemia/mortalidad , Isquemia/cirugía , Recuperación del Miembro/mortalidad , Extremidad Inferior/cirugía , Injerto Vascular , Anciano de 80 o más Años , Procedimientos Endovasculares , Femenino , Humanos , Extremidad Inferior/irrigación sanguínea , Masculino , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVES: This study aims to evaluate the feasibility of external polyester scaffolding in infrainguinal bypass grafting when available vein material is suboptimal due to varicosity or dilatation. Primary objectives were short-term primary patency, assisted primary patency and secondary patency. Secondary objectives were to assess the rate of graft stenoses, infections and other adverse effects related to the use of external scaffolding. MATERIALS AND METHODS: A total of 50 consecutive patients were included in this prospective, multicentre, feasibility study from six centres. The indication for infrainguinal bypass was critical limb ischaemia (64%), severe claudication (34%) or popliteal aneurysm (2%). Indications for the use of the external scaffolding were varicosity of the vein graft, ectatic vein graft or the use of spliced vein grafts with segments of widely differing diameters. Duplex scanning of the graft was done perioperatively and at follow-up visits at 1, 3, 6 and 12 months after operation. RESULTS: Primary patency, assisted primary patency and secondary patency at 6 months were 82.3% (+/-SE 6.2%), 88.6% (+/-SE 4.8%) and 92.1% (+/-SE 4.4%), respectively. Six graft stenoses were detected in duplex surveillance. There were no infections related to polyester mesh. CONCLUSIONS: External scaffolding of infrainguinal vein grafts may be a promising innovation. Early results from this multicentre study show that polyester mesh is safe and feasible adjunct to peripheral revascularization enabling the use of otherwise non-optimal vein grafts with acceptable short-term patency.
Asunto(s)
Extremidad Inferior/irrigación sanguínea , Enfermedades Vasculares Periféricas/cirugía , Poliésteres , Mallas Quirúrgicas , Procedimientos Quirúrgicos Vasculares/instrumentación , Venas/trasplante , Adulto , Anciano , Anciano de 80 o más Años , Aneurisma/cirugía , Diseño de Equipo , Estudios de Factibilidad , Femenino , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/cirugía , Humanos , Claudicación Intermitente/etiología , Claudicación Intermitente/cirugía , Isquemia/etiología , Isquemia/cirugía , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Enfermedades Vasculares Periféricas/complicaciones , Enfermedades Vasculares Periféricas/diagnóstico , Enfermedades Vasculares Periféricas/fisiopatología , Flebografía , Proyectos Piloto , Arteria Poplítea/cirugía , Estudios Prospectivos , Reoperación , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/cirugía , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Doppler Dúplex , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos Vasculares/efectos adversos , Venas/patologíaRESUMEN
We coimmobilized mast cell-derived heparin proteoglycans (HEP-PGs) of very high molecular weight (750 kDa) or unfractionated heparin (UFH) on coverslips together with collagen without altering the amount of immobilized collagen. Subsequently, platelet-collagen interactions were studied under both flowing and static conditions in D-phenylalanyl-L-prolyl-L-arginine chloromethyl ketone-anticoagulated blood and platelet-rich plasma (PRP), respectively. At a high shear rate (1600 1/s), the mean platelet deposition (PD) on collagen monomers was 7.5+/-6.1x10(6)/cm(2) (n=5). When the monomers were coimmobilized with UFH, PD was inhibited by 73% (2.0+/-1.2x10(6)/cm(2)), whereas HEP-PG completely blocked it (0. 42+/-0.38x10(6)/cm(2); P<0.05). Also, when collagen fibrils were used for coating, HEP-PG significantly inhibited PD. At a low shear rate (200 1/s) and under static conditions in PRP, the inhibitory effect of HEP-PG on PD was less marked. Inhibition of glycoprotein IIb/IIIa did not affect PD on coimmobilized HEP-PG in contrast to coimmobilized UFH or collagen alone. As a sign of inactivation, platelets adhering to the HEP-PG surface released considerably less beta-thromboglobulin than did those adhering to pure collagen. In summary, immobilized HEP-PG strongly inhibited PD on collagen by attenuating adhesion-induced platelet activation. The stronger effect on collagen monomers suggests the inhibition of glycoprotein Ia/IIa-mediated activation.
Asunto(s)
Plaquetas/metabolismo , Colágeno/antagonistas & inhibidores , Colágeno/sangre , Proteoglicanos de Heparán Sulfato/sangre , Proteoglicanos de Heparán Sulfato/fisiología , Inhibidores de Agregación Plaquetaria/farmacología , Animales , Velocidad del Flujo Sanguíneo , Plaquetas/química , Glicosaminoglicanos/sangre , Proteoglicanos de Heparán Sulfato/aislamiento & purificación , Heparina/sangre , Heparina/farmacología , Humanos , Sustancias Macromoleculares , Mastocitos/química , Perfusión , Inhibidores de Agregación Plaquetaria/sangre , Ratas , beta-Tromboglobulina/metabolismo , Factor de von Willebrand/metabolismoRESUMEN
We studied the effects of stimulated skin mast cells on bleeding time and thrombin generation which was measured using prothrombin fragment F 1+2 (F 1+2) and thrombin-antithrombin-III-complex (TAT). In 10 patients with urticaria pigmentosa (chronic cutaneous mast cell accumulation) the mean bleeding time was significantly prolonged in wounds made on urticaria pigmentosa lesions vs. normal skin (460 +/- 34 vs. 342 +/- 27 s, p = 0.005). In 10 atopic subjects skin incisions were made on prick-tested sites 30, 60, 120 and 240 min after administration of an allergen (acute mast cell stimulation), histamine or vehicle. The mean bleeding time was significantly prolonged at all time points, being maximal at 120 min (60% prolonged) in wounds made on allergen-stimulated skin areas (p < 0.01) compared with histamine or vehicle sites. Administration of allergen or histamine lowered the TAT concentration in the bleeding-time blood. Furthermore, TAT and F 1+2 levels in the bleeding-time blood were lower at 60, 120 and 240 min after allergen or histamine application in comparison with samples collected at 30 min. We conclude that skin mast cells can regulate primary hemostasis by prolonging bleeding time and by inhibiting thrombin generation.
Asunto(s)
Tiempo de Sangría , Hipersensibilidad Inmediata/sangre , Mastocitos/fisiología , Piel/patología , Urticaria Pigmentosa/sangre , Adulto , Alérgenos , Antitrombina III/análisis , Plaquetas/fisiología , Femenino , Histamina , Liberación de Histamina , Humanos , Masculino , Persona de Mediana Edad , Fragmentos de Péptidos/análisis , Péptido Hidrolasas/análisis , Proteoglicanos/fisiología , Protrombina/análisis , Piel/lesiones , Pruebas Cutáneas , Trombina/biosíntesisRESUMEN
BACKGROUND: Intimal smooth muscle cell proliferation is an underlying pathogenetic mechanism for neointimal hyperplasia and consequent vein graft failure. This study characterizes the expression of tissue-type plasminogen activator (TPA), urokinase-type plasminogen activator (UPA), and plasminogen activator inhibitor-1 (PAI-1) in hyperplastic vein grafts and normal venous tissue. METHODS AND RESULTS: Failing graft and control vein specimens from 14 donors were homogenized, and TPA and PAI-1 were quantified with ELISA. The amount of PAI-1 was seven times higher (4.2+/-2.1 versus 0.6+/-0.6 ng/mg protein, P<.005), but the TPA antigen content was markedly lower (3.1+/-2.1 versus 8.1+/-3.7 ng/mg protein, P<.005) in the stenosed grafts compared with the control veins. Strong immunohistochemical PAI-1 reactivity and in situ hybridization signals for PAI-1 and UPA mRNA were associated with the smooth muscle cells of the thickened intima of the grafts. Functional assays of the graft specimens showed an increased UPA/TPA ratio and a decreased total fibrinolytic activity in comparison with normal veins. CONCLUSIONS: Upregulation of PAI-1 mRNA expression and markedly increased amounts of PAI-1 antigen were detected in the vein grafts after the development of neointima. Furthermore, augmented UPA activity was found in the graft wall, but TPA was clearly depleted. Altogether, our findings imply decreased fibrinolytic potential in the stenosed graft, which may contribute to the graft occlusion.
Asunto(s)
Supervivencia de Injerto/fisiología , Inhibidor 1 de Activador Plasminogénico/análisis , Inhibidores de Serina Proteinasa/análisis , Túnica Íntima/química , Venas/trasplante , Fibrina/metabolismo , Fibrinolíticos/análisis , Fibrinolíticos/metabolismo , Fibrinolíticos/farmacología , Humanos , Técnicas para Inmunoenzimas , Inmunohistoquímica , Hibridación in Situ , Inhibidor 1 de Activador Plasminogénico/genética , Inhibidor 1 de Activador Plasminogénico/farmacología , Activadores Plasminogénicos/análisis , Activadores Plasminogénicos/genética , Activadores Plasminogénicos/metabolismo , ARN Mensajero/análisis , Inhibidores de Serina Proteinasa/genética , Inhibidores de Serina Proteinasa/farmacología , Activador de Tejido Plasminógeno/análisis , Activador de Tejido Plasminógeno/metabolismo , Activador de Tejido Plasminógeno/farmacología , Túnica Íntima/enzimología , Activador de Plasminógeno de Tipo Uroquinasa/análisis , Activador de Plasminógeno de Tipo Uroquinasa/genética , Activador de Plasminógeno de Tipo Uroquinasa/metabolismo , Venas/química , Venas/enzimologíaRESUMEN
Hemostatic variables and platelet function were assessed as a part of a genetic study in 15 patients with symptomatic peripheral arterial occlusive disease (PAOD) and 15 healthy siblings from ten families. D-dimer, a degradation product of cross-linked fibrin, was increased in the PAOD group (mean +/- SD) (448 +/- 177 vs. 333 +/- 121 ng/ml, p < 0.05). Ristocetin-induced maximal platelet aggregation (RIPA) was reduced in the PAOD group in response to both a higher (0.75 mg/ml) (67 +/- 28 vs. 87 +/- 14%, p = 0.02) and a lower (0.55 or 0.60 mg/ml) (33 +/- 21 vs. 59 +/- 32%, p = 0.02) concentration of ristocetin. Accordingly, the rate of primary aggregation was smaller, and a larger threshold concentration of ristocetin was needed to cause aggregation. However, ristocetin cofactor activity, von Willebrand factor (vWF) antigen and its multimer distribution, plasma glycocalicin, platelet glycoprotein Ib content and the binding of vWF to frozen and thawed washed platelets were equal in both groups. Thus, the observed reduced RIPA in patients with PAOD is less likely to reflect a down-regulation or blunted binding affinity in the platelet surface glycoprotein Ib.
Asunto(s)
Arteriopatías Oclusivas/sangre , Arteriopatías Oclusivas/genética , Plaquetas/fisiología , Complejo GPIb-IX de Glicoproteína Plaquetaria/metabolismo , Factor de von Willebrand/metabolismo , Anciano , Recuento de Células Sanguíneas , Colesterol/sangre , Femenino , Fibrinógeno/análisis , Fibrinólisis , Finlandia , Humanos , Masculino , Persona de Mediana Edad , Núcleo Familiar , Agregación Plaquetaria/efectos de los fármacos , Valores de Referencia , Ristocetina/farmacología , Triglicéridos/sangreRESUMEN
The importance of the distinction between acute embolic ischaemia and acute on chronic ischaemia caused by a thrombus superimposed on an arteriosclerotic stenoses has been emphasized during the recent years, as the differentiation should affect the choice of surgical treatment. A retrospective attempt was made to differentiate between acute ischaemia (AI = embolism) and acute on chronic ischaemia (AOCI = thrombosis) of the leg by categorizing the patients according to the clinical characteristics they presented. The material consisted of 194 ischaemic lower limbs of 189 patients who underwent a balloon-catheter thromboembolectomy because of sudden arterial occlusion. The retrospective diagnosis of AI was made in 94 (48%) and AOCI in 69 (36%) cases. The preoperative assessment could not be done in 43 (22%) patients by surgeon working at the emergency room. The retrospective distinction was impossible in 31 (16%) patients. The preoperative diagnosis was in better agreement with the retrospective category when AI, as opposed to AOCI, was the aetiology of occlusion (70% vs 46%). The results of the present study emphasize the difficulties of clinical assessment. These findings suggest a routine angiography as an evaluative tool in the planning of optimal management especially as most of the patients today can be treated simultaneously by thrombolysis.
Asunto(s)
Isquemia/diagnóstico , Pierna/irrigación sanguínea , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Arteriosclerosis/complicaciones , Arteriosclerosis/diagnóstico , Arteriosclerosis/cirugía , Enfermedad Crónica , Diagnóstico Diferencial , Embolectomía , Femenino , Humanos , Isquemia/etiología , Isquemia/cirugía , Pierna/cirugía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Trombectomía , Tromboembolia/complicaciones , Tromboembolia/diagnóstico , Tromboembolia/cirugíaRESUMEN
Immunohistochemical studies of human atherosclerotic lesions have demonstrated the occurrence of fibrin deposition and its degradation in the arterial wall. We studied fibrinogen, the generation of thrombin, and the degradation of fibrin in 40 patients with stable peripheral arterial occlusive disease of varying severity, as assessed by the ankle/brachial pressure index and duplex ultrasonography and/or angiography. Circulating fibrinogen (functional and immunological), fibrinopeptide A, thrombin-antithrombin III complex, and D-dimer were measured. The severity of atherosclerosis was associated with both fibrinogen (both functional and immunological) and D-dimer (r = .57, P < .0002, and r = .57, P < .0001, respectively). Fibrinogen and D-dimer showed a significant positive correlation (r = .50, P < .001). Generation of thrombin was detected in 24 patients (60%) by fibrinopeptide A and levels of thrombin-antithrombin III complex. As a sign of coagulation activation and fibrinolysis, we found that thrombin-antithrombin III complex and the degradation of cross-linked fibrin were progressively associated with the extent of vascular disease. The plasmin-mediated fibrin breakdown contributed to increased levels of circulating fibrinogen, an established risk factor for thrombotic complications. The significant correlations between fibrinogen/D-dimer and the severity of atherosclerosis support previous pathological studies and imply that local degradation of cross-linked fibrin is involved in the progression of atherosclerosis.