RESUMEN
The management of embolic acute limb ischaemia commonly involves determining aetiology and performing emergency invasive procedures. This detailed study aimed to determine the impact of manipulation of anticoagulation in the aetiology of emboli in acute limb ischaemia and determine the efficacy of primary anticoagulation therapy vs. invasive interventions. Material and methods: Data collection was conducted at a single institution on a cohort of patients presenting consecutively with embolic acute limb ischaemia over one year. Two groups were compared, one receiving anticoagulation as primary therapy with those undergoing invasive treatment as the internal comparison group. Results: A likely haematological causation was identified in 22 of 38 presentations, related to interruption of anticoagulation in cardiac conditions, the majority atrial fibrillation (n=12), or hypercoagulable states (n=10). Limb salvage was pursued in 36 patients employing anticoagulation (n=19) or surgical embolectomy (n=17) as the primary therapy in upper and lower limbs (n=17 vs n=19 respectively). Despite delays often well beyond six hours and a range of ischaemic severity in both groups, 35 of 36 patients achieved full or substantive restoration of function with improved perfusion. Regarding anatomical distribution of arterial disease and therapy, three patients with multi-level disease proceeded to embolectomy following anticoagulation. Embolectomy was undertaken most often for proximal emboli and more profound paralysis. Conclusions: Anticoagulation and coagulopathy are commonly implicated in the aetiology of arterial emboli, with omission of effective anticoagulation in atrial fibrillation being associated in almost 1/3 of presentations. Whilst more profound limb paralysis and proximal or multi-level disease tended to be managed surgically, primary anticoagulation therapy alone or with a secondary embolectomy was effective across the spectrum of ischaemia severity and despite significant delays beyond guideline recommendations.
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Anticoagulantes , Embolectomía , Embolia , Isquemia , Recuperación del Miembro , Humanos , Anticoagulantes/uso terapéutico , Anticoagulantes/efectos adversos , Femenino , Masculino , Anciano , Embolectomía/efectos adversos , Isquemia/tratamiento farmacológico , Isquemia/diagnóstico , Resultado del Tratamiento , Embolia/etiología , Embolia/prevención & control , Embolia/diagnóstico , Enfermedad Aguda , Persona de Mediana Edad , Anciano de 80 o más Años , Factores de Tiempo , Factores de Riesgo , Estudios Retrospectivos , Enfermedad Arterial Periférica/tratamiento farmacológico , Enfermedad Arterial Periférica/diagnóstico , Recuperación de la FunciónRESUMEN
Acute limb ischemia (ALI) due to arterial thromboembolic occlusion is a critical emergency in vascular medicine, requiring attention for rapid diagnosis and intervention, to prevent limb loss and major amputation, which is associated with patient disability in the long term. Traditionally, surgical embolectomy has been used for the treatment of ALI. Endovascular treatment of ALI traditionally involved catheter-directed thrombolysis. This option, however, poses some limitations, including an increased risk for access site and systemic bleeding complications, especially in patients with high bleeding risk. Therefore, in the last decades, several devices have been developed and tested for the mechanical endovascular treatment of ALI. Such devices involve either rotational thrombectomy or continuous thrombus aspiration. While rotational thrombectomy is limited in rather large arteries due to the risk of dissection and perforation in arteries <3 mm, continuous thrombus aspiration can be applied in smaller vessels and tortuous anatomies. In our case series we present a minimal-invasive endovascular approach for the treatment of two patients with ALI due to thrombotic occlusion of tortious and small diameter arteries. Minimal-invasive mechanical thrombectomy using the Penumbra Aspiration System emerged as a successful alternative to surgical embolectomy, enabling prompt treatment and with a short hospital stay for both patients. Our article therefore highlights the use of continuous thrombus aspiration in small diameter vessels and tortuous anatomies, which may represent a contraindication for the use of rotational thrombectomy. In addition, this technique may be applied even in patients with higher bleeding risk since additional lysis is not necessary in patients, where complete thrombus removal can be achieved by this device.
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Procedimientos Endovasculares , Trombectomía , Humanos , Trombectomía/instrumentación , Trombectomía/efectos adversos , Resultado del Tratamiento , Masculino , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/efectos adversos , Anciano , Femenino , Isquemia/diagnóstico , Isquemia/cirugía , Isquemia/terapia , Persona de Mediana Edad , Tromboembolia/etiología , Tromboembolia/diagnóstico , Enfermedad AgudaRESUMEN
AIMS: To explore the sensitive components of full-field electroretinography (ERG) as indicators of retina function at the onset of acute ischaemic central retinal vein occlusion (CRVO). METHODS: 11 patients (11 eyes) with ischaemic CRVO and 32 patients (32 eyes) with non-ischaemic CRVO who presented with first-episode unilateral CRVO within 1 month of symptom onset and with no previous intervention were examined by the International Society for Clinical Electrophysiology of Vision standard ERG. RESULTS: A significant amplitude decline and peak time delay in light-adapted (LA) 3 ERG and LA 30 Hz flicker ERG (p<0.05 for all) was found in the ischaemic CRVO eyes, compared with the non-ischaemic CRVO eyes. The b/a amplitude ratio of dark-adapted (DA) 3 ERG, DA 10 ERG and LA 3 ERG was significantly different between the ischaemic and non-ischaemic groups (p<0.05 for all). Regarding oscillatory potentials (OPs), the amplitudes of OP1, OP2 and OP3 as well as the sum of DA 3 OP1-4 amplitudes (∑OPs) showed significant changes (p<0.01 for all) between two groups. No peak time delay of OPs was found between the ischaemic and non-ischaemic CRVO eyes. CONCLUSION: The amplitude of DA 0.01 ERG, components of LA 3 ERG and LA 30 Hz flicker ERG, and the b/a amplitude ratio could be among the most sensitive indicators in patients with acute ischaemic CRVO. The amplitudes of OP1, OP2, OP3 and ∑OPs in the CRVO eyes were reduced to 40% of the control values, showing that this quantitative method is reliable for detecting ischaemic retinal diseases, even in early stage.
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Electrorretinografía , Isquemia , Retina , Oclusión de la Vena Retiniana , Humanos , Oclusión de la Vena Retiniana/fisiopatología , Oclusión de la Vena Retiniana/diagnóstico , Electrorretinografía/métodos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Enfermedad Aguda , Isquemia/fisiopatología , Isquemia/diagnóstico , Retina/fisiopatología , Retina/diagnóstico por imagen , Agudeza Visual/fisiología , Adaptación a la Oscuridad/fisiología , AdultoRESUMEN
BACKGROUND/AIM: Chronic lower limb ischaemia is a peripheral arterial disease (PAD) which is typically instigated by atherosclerotic plaques in the peripheral vasculature. This article reports on a unique case of chronic ischaemia in the lower limb, presenting in a distinctive manner as a fungal toenail infection. CASE REPORT: An 82-year-old frail woman with multimorbidity presented with toenail symptoms in her right foot. While initial examination had shown onychomycosis, further investigation was unexpectedly consistent with chronic ischaemia in the lower limb. We explored the clinical presentation, diagnostic challenges encountered, and the subsequent management of this unique manifestation in the context of the patient's multimorbidity. CONCLUSION: This case report highlights the need to consider chronic limb ischemia as a differential diagnosis in toenail infections when no alternative causes or predisposing factors are identified.
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Onicomicosis , Humanos , Femenino , Anciano de 80 o más Años , Onicomicosis/diagnóstico , Onicomicosis/microbiología , Diagnóstico Diferencial , Extremidad Inferior/irrigación sanguínea , Isquemia/diagnóstico , Isquemia/etiología , Isquemia Crónica que Amenaza las Extremidades/diagnóstico , Enfermedad Arterial Periférica/diagnósticoRESUMEN
Chronic limb threatening ischemia (CLTI) poses a significant treatment challenge for vascular surgeons, interventionalists, podiatrists, and associated medical specialists. The evidence for what constitutes appropriate care is rapidly evolving and new treatment options are in constant development. This review examines the current guidelines for CLTI care, as well as reported outcomes for multiple care strategies in this patient population, including revascularization and medical optimization. We performed a literature review of the PubMed database, reviewing articles that reported outcomes for CLTI care between 2000 and 2023, and described these outcomes as they relate to the current state of CLTI treatment. Significant data are still forthcoming regarding CLTI care, but widespread adoption of appropriate CLTI care is essential for the treatment of this vulnerable population.
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Isquemia Crónica que Amenaza las Extremidades , Humanos , Resultado del Tratamiento , Factores de Riesgo , Isquemia Crónica que Amenaza las Extremidades/terapia , Procedimientos Quirúrgicos Vasculares/normas , Procedimientos Quirúrgicos Vasculares/efectos adversos , Enfermedad Arterial Periférica/terapia , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/fisiopatología , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/normas , Medicina Basada en la Evidencia/normas , Guías de Práctica Clínica como Asunto , Isquemia/terapia , Isquemia/diagnóstico , Isquemia/fisiopatología , Recuperación del Miembro , Enfermedad CrónicaRESUMEN
OBJECTIVE: The objective of this study is to conduct a comprehensive bibliometric analysis to elucidate the landscape of machine learning applications in ischemia research. METHODS: The analysis can be divided in three sections: part 1 scrutinizes articles and reviews with "ischemia" in their titles, while part 2 further narrows the focus to publications containing both "ischemia" and "machine learning" in their titles. Additionally, part 3 delves into the examination of the top 50 most cited papers, exploring their thematic focus and co-word dynamics. RESULTS: The findings reveal a significant increase in publications over the years, with notable trends identified through detailed analysis. The growth in publication counts over time, the leading contributors, institutions, geographical distribution of research output and journals are numerically presented for part 1 and part 2. For the top 50 most cited papers the dynamics of co-words, which offer a nuanced understanding of thematic trends and emerging concepts, are presented. Based on the number of citations the top 10 authors were selected, and later for each, total number of publications, h-index, g-index and m-index are provided. Additionally, figures depicting the co-authorship network among authors, departments, and countries involved in the top 50 cited papers may enrich our comprehension of collaborative networks in ischemia research. CONCLUSION: This comprehensive bibliometric analysis provides valuable insights into the evolving landscape of machine learning applications in ischemia research.
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Bibliometría , Investigación Biomédica , Isquemia , Aprendizaje Automático , Humanos , Investigación Biomédica/métodos , Isquemia/diagnósticoRESUMEN
BACKGROUND: To examine the influence of liver function on patients with chronic limb-threatening ischemia (CLTI), we classified patients with CLTI after revascularization according to their modified albumin-bilirubin (ALBI) grades. METHODS: We retrospectively analyzed single-center data of patients who underwent revascularization for CLTI between 2015 and 2020. Patients were classified with ALBI grades 1, 2a, and 2b and 3 according to the ALBI score, which was calculated, based on serum albumin and total bilirubin levels. The endpoints were the 2-year amputation-free survival (AFS) and 1-year wound healing rates. RESULTS: We included 190 limbs in 148 patients, and 50, 54, and 86 cases were assigned as grade 1, 2a, and 2b and 3, respectively. The 2-year AFS rates for the grade 1, 2a, and 2b and 3 groups were 79 ± 6%, 66% ± 7%, and 45 ± 6%, respectively (P < 0.01). One-year cumulative wound healing rates for grade 1, 2a, and 2b and 3 groups were 68 ± 7%, 69% ± 6%, and 48% ± 5%, respectively (P = 0.01). Multivariate Cox proportional hazard analyses identified age (≥75 years), dependent ambulatory status, and modified ALBI grades 2b and 3 compared with grades 1 and 2a as significant independent predictors of AFS. The dependent ambulatory status and Wound, Ischemia, and foot Infection classification stage 4 were significant negative predictors of wound healing. CONCLUSIONS: Many patients with CLTI had high modified ALBI grades, and impaired liver function classified as modified ALBI grade 2b and 3 is a robust negative predictor of AFS.
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Amputación Quirúrgica , Bilirrubina , Biomarcadores , Recuperación del Miembro , Enfermedad Arterial Periférica , Valor Predictivo de las Pruebas , Albúmina Sérica Humana , Cicatrización de Heridas , Humanos , Masculino , Femenino , Estudios Retrospectivos , Anciano , Bilirrubina/sangre , Albúmina Sérica Humana/análisis , Biomarcadores/sangre , Factores de Tiempo , Persona de Mediana Edad , Factores de Riesgo , Anciano de 80 o más Años , Medición de Riesgo , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/sangre , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/cirugía , Isquemia Crónica que Amenaza las Extremidades/cirugía , Isquemia Crónica que Amenaza las Extremidades/sangre , Isquemia Crónica que Amenaza las Extremidades/diagnóstico , Isquemia Crónica que Amenaza las Extremidades/mortalidad , Resultado del Tratamiento , Supervivencia sin Progresión , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidad , Pruebas de Función Hepática , Isquemia/sangre , Isquemia/diagnóstico , Isquemia/cirugía , Isquemia/fisiopatología , Isquemia/mortalidadRESUMEN
BACKGROUND: The aim of this study is to present short- and long-term outcomes after lower extremity bypass (LEB) surgery in patients with chronic limb-threatening ischemia and chronic kidney disease (CKD), differentiated by peripheral artery disease (PAD) Fontaine stage III and IV. METHODS: Retrospective analysis of anonymized data from a nationwide German health insurance company (AOK). Data from 22,633 patients (14,523 men) who underwent LEB from 2010 to 2015 were analyzed, presenting 18,271 with CKD stage 1/2, 2,483 patients with CKD stage 3, and 1,879 with CKD stage 4/5. RESULTS: Perioperative mortality (60-day mortality) was 7.2% for CKD stage 1/2, 12.4% for CKD stage 3, and 19.8% for CKD stage 4/5. Patients with PAD stage IV had significantly higher perioperative mortality (10.3%) than patients with PAD stage III (4.5%). The perioperative major amputation rate depended significantly on PAD stage IV (odds ratio [OR]: 2.57 confidence interval [CI]: 2.16-3.05, P < 0.001), the LEB level below the knee and crural/pedal (OR: 2.49 CI: 2.14-2.90, P < 0.001), CKD stage 4/5 (OR: 1.28, CI: 1.06-1.54, P = 0.009), and the presence of diabetes mellitus type 2 (OR: 1.19, CI: 1.05-1.36, P = 0.007). Kaplan-Meier estimated long-term survival of up to 9 years after surgery was 31.7% for patients with CKD stage 1 and 2, 14.3% for CKD stage 3, and only 10.1% for CKD stage 4 and 5 (P < 0.001). PAD Fontaine stage IV versus III (hazard ratio: 1.64, CI: 1.56-1.71, P < 0.001), but not bypass level, had an independent adverse influence on long-term survival. CONCLUSION: CKD and PAD stage were equally significant independent predictors of patient survival and major adverse cardiovascular events with higher PAD and CKD stages associated with less favorable long-term outcomes.
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Amputación Quirúrgica , Enfermedad Crítica , Recuperación del Miembro , Extremidad Inferior , Enfermedad Arterial Periférica , Insuficiencia Renal Crónica , Humanos , Masculino , Femenino , Alemania , Estudios Retrospectivos , Factores de Tiempo , Anciano , Enfermedad Arterial Periférica/cirugía , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/diagnóstico , Insuficiencia Renal Crónica/mortalidad , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/diagnóstico , Resultado del Tratamiento , Factores de Riesgo , Persona de Mediana Edad , Extremidad Inferior/irrigación sanguínea , Anciano de 80 o más Años , Medición de Riesgo , Isquemia Crónica que Amenaza las Extremidades/cirugía , Isquemia Crónica que Amenaza las Extremidades/mortalidad , Isquemia Crónica que Amenaza las Extremidades/complicaciones , Isquemia/cirugía , Isquemia/mortalidad , Isquemia/diagnóstico , Bases de Datos Factuales , Injerto Vascular/efectos adversos , Injerto Vascular/mortalidad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/etiologíaRESUMEN
Central retinal artery occlusion (CRAO), a type of acute retinal arterial ischemia, analogous to an ocular stroke, is a medical emergency that warrants immediate diagnosis and treatment. CRAO usually presents with sudden, painless, monocular vision loss. Ipsilateral carotid artery disease is an important associated finding in these patients. The primary limitation to effective treatment of CRAO is that patients are rarely seen in the acute stage. Moreover, there are no guidelines for effective treatment. We report a patient with right CRAO whose treatment with intravenous thrombolysis with tenecteplase and anterior chamber paracentesis with ocular massage resulted in a good clinical outcome.
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Fibrinolíticos , Oclusión de la Arteria Retiniana , Tenecteplasa , Terapia Trombolítica , Humanos , Tenecteplasa/uso terapéutico , Tenecteplasa/administración & dosificación , Fibrinolíticos/uso terapéutico , Oclusión de la Arteria Retiniana/diagnóstico , Oclusión de la Arteria Retiniana/tratamiento farmacológico , Terapia Trombolítica/métodos , Enfermedad Aguda , Masculino , Activador de Tejido Plasminógeno/uso terapéutico , Activador de Tejido Plasminógeno/administración & dosificación , Isquemia/diagnóstico , Isquemia/tratamiento farmacológico , Persona de Mediana Edad , Angiografía con Fluoresceína/métodos , Femenino , AncianoRESUMEN
INTRODUCTION: Delays exist at each stage of the chronic limb-threatening ischaemia (CLTI) care pathway, but there is little known about patient factors influencing delay to diagnosis of CLTI. This study explores the experiences and perceptions of patients recently diagnosed with CLTI. METHODS: A qualitative interview study was conducted. Sixteen participants underwent semi-structured interviews. Reflexive thematic analysis was performed on the data, aiming to understand factors which can influence delay in the CLTI care pathway. RESULTS: Five interrelated themes were developed: CLTI is a devastating condition; Reluctance to ask for help; When we are empowered we get better care; Luck plays a role in the process to diagnosis; and Vascular units can do better, comprising sub-themes of information transfer-consider communication and arterial versus non-arterial centres-proximity isn't everything. CONCLUSIONS: The five themes generated from the interview data describe factors relevant to delay given meaning by participants who have lived experience of CLTI. Theme content should be noted by clinicians, commissioners and providers looking to improve care pathways for patients with CLTI. The importance of awareness for the public, patients and clinicians linked ideas in some themes and interventions to raise awareness should be considered.
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Investigación Cualitativa , Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Diagnóstico Tardío , Isquemia Crónica que Amenaza las Extremidades/diagnóstico , Isquemia Crónica que Amenaza las Extremidades/psicología , Adulto , Isquemia/diagnóstico , Isquemia/psicología , Anciano de 80 o más Años , Enfermedad Crónica , Entrevistas como AsuntoRESUMEN
BACKGROUND: The treatment of acute lower limb ischemia (ALLI) has evolved over the last several decades with the availability of several new treatment modalities. This study was undertaken to evaluate the contemporary presentation and outcomes of ALLI patients. METHODS: We retrospectively analyzed data from a prospectively collected database of all patients who presented to our tertiary referral hospital with acute ischemia of the lower extremity between May 2016 and October 2020. The cause of death was obtained from the Michigan State Death Registry. RESULTS: During the study period, 233 patients (251 lower limbs) were evaluated for ALLI. Seventy-three percent had thrombotic occlusion, 24% had embolic occlusion, and 3% due to a low flow state. Rutherford classification of ischemia severity was 7%, 49%, 40%, and 4% for Rutherford grade I, IIA, IIB, and III, respectively. Five percent underwent primary amputations, and 6% received medical therapy only. The mean length of stay was 11 ± 9 days. Nineteen percent of patients were readmitted within 30 days of discharge. At 30 days postoperatively, mortality was 9% and limb loss was 19%. On multivariate analysis, 1 or no vessel runoff to the foot postoperatively was associated with higher 30-day limb loss. Patients with no run-off vessels postoperatively had significantly higher 30-day mortality. Cardiovascular complications accounted for most deaths (48%). At 1-year postoperatively, mortality and limb loss reached 17% and 34%, respectively. CONCLUSIONS: Despite advances in treatment modalities and cardiovascular care, patients presenting with ALLI continue to have high mortality, limb loss, and readmission rates at 30 days.
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Amputación Quirúrgica , Bases de Datos Factuales , Isquemia , Extremidad Inferior , Enfermedad Arterial Periférica , Humanos , Masculino , Femenino , Isquemia/mortalidad , Isquemia/terapia , Isquemia/diagnóstico , Isquemia/cirugía , Estudios Retrospectivos , Anciano , Extremidad Inferior/irrigación sanguínea , Factores de Riesgo , Factores de Tiempo , Persona de Mediana Edad , Resultado del Tratamiento , Enfermedad Aguda , Anciano de 80 o más Años , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/terapia , Enfermedad Arterial Periférica/diagnóstico , Readmisión del Paciente , Medición de Riesgo , Recuperación del Miembro , Michigan/epidemiología , Sistema de Registros , Tiempo de InternaciónRESUMEN
BACKGROUND: Adhesive small bowel obstruction (ASBO) is a leading cause of hospitalization in emergency surgery. The occurrence of bowel ischemia significantly increases the morbidity and mortality rates associated with this condition. Current clinical, biochemical and radiological parameters have poor predictive value for bowel ischemia. This study is designed to ascertain predictive elements for the progression to bowel ischemia in patients diagnosed with non-strangulated ASBO who are initially managed through conservative therapeutic approaches. METHODS: The study was based on the previously collected medical records of 128 patients admitted to the Department of Acute Care Surgery of Padua General Hospital, from August 2020 to April 2023, with a diagnosis of non-strangulated adhesive small bowel obstruction, who were then operated for failure of conservative treatment. The presence or absence of bowel ischemia was used to distinguish the two populations. Clinical, biochemical and radiological data were used to verify whether there is a correlation with the detection of bowel ischemia. RESULTS: We found that a Neutrophil-Lymphocyte ratio (NLR) > 6.8 (OR 2.9; 95% CI 1.41-6.21), the presence of mesenteric haziness (OR 2.56; 95% CI 1.11-5.88), decreased wall enhancement (OR 4.3; 95% CI 3.34-10.9) and free abdominal fluid (OR 2.64; 95% CI 1.08-6.16) were significantly associated with bowel ischemia at univariate analysis. At the multivariate logistic regression analysis, only NLR > 6.8 (OR 5.9; 95% CI 2.2-18.6) remained independent predictive factor for small bowel ischemia in non-strangulated adhesive small bowel obstruction, with 78% sensitivity and 65% specificity. CONCLUSIONS: NLR is a straightforward and reproducible parameter to predict bowel ischemia in cases of non-strangulated adhesive small bowel obstruction. Employing NLR during reevaluation of patients with this condition, who were initially treated conservatively, can help the acute care surgeons in the early prediction of bowel ischemia onset.
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Obstrucción Intestinal , Intestino Delgado , Linfocitos , Neutrófilos , Humanos , Estudios Retrospectivos , Obstrucción Intestinal/etiología , Obstrucción Intestinal/diagnóstico , Obstrucción Intestinal/cirugía , Masculino , Femenino , Anciano , Intestino Delgado/irrigación sanguínea , Intestino Delgado/patología , Persona de Mediana Edad , Linfocitos/patología , Adherencias Tisulares/diagnóstico , Isquemia/diagnóstico , Isquemia/etiología , Valor Predictivo de las Pruebas , Anciano de 80 o más Años , AdultoRESUMEN
INTRODUCTION: The identification of novel, easily measurable disease biomarkers might enhance the diagnosis and management of patients with rheumatic diseases (RDs). We conducted a systematic review and meta-analysis of ischemia-modified albumin (IMA), a marker of oxidative stress, acidosis, and ischemia, in RD patients and healthy controls. METHODS: We searched PubMed, Web of Science, and Scopus from inception to January 15, 2024. The risk of bias and the certainty of evidence were assessed using the Joanna Briggs Institute Critical Appraisal Checklist and GRADE, respectively. RESULTS: In 20 studies investigating a total of 1188 RD patients (mean age 45 years, 64% females) and 981 healthy controls (mean age 44 years, 66% females), RD patients had significantly higher IMA concentrations when compared to controls (standard mean difference, SMD = 0.50, 95% CI: 0.18-0.83, p = .003; I2 = 92.4%, p < .001; low certainty of evidence). In subgroup analysis, the pooled SMD was significantly different in studies investigating ankylosing spondylitis (p < .001), Behçet's disease (p < .001), and rheumatoid arthritis (p = .033), but not familial Mediterranean fever (p = .48). Further associations were observed between the pooled SMD and the broad classification of autoimmune and/or autoinflammatory diseases, the study country, and the method used to measure IMA. CONCLUSION: Our study suggests that IMA is a promising biomarker of oxidative stress, acidosis, and ischemia, as it can effectively discriminate between patients with different types of RDs and healthy controls. Our results warrant confirmation in longitudinal studies of patients with different types of RDs and different ethnicities (PROSPERO registration number: CRD42024509126).
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Biomarcadores , Estrés Oxidativo , Enfermedades Reumáticas , Albúmina Sérica Humana , Humanos , Enfermedades Reumáticas/sangre , Enfermedades Reumáticas/diagnóstico , Biomarcadores/sangre , Albúmina Sérica Humana/análisis , Femenino , Isquemia/sangre , Isquemia/diagnóstico , Masculino , Persona de Mediana EdadRESUMEN
We present a case of diagnostic interest; we present the differential diagnosis and the complementary tests necessary to reach it, in addition to highlighting the importance of a correct collection of background and clinical history. A 54-year-old woman with a history of carcinoma of the floor of the mouth treated with radiotherapy and chemotherapy develops ischemic retinopathy. It was necessary to perform a systemic study and differential diagnosis with entities such as ocular ischemic syndrome and radiation retinopathy, due to the similarity in the clinical findings found. Radiation retinopathy should be ruled out in any patient with visual impairment and a history of radiotherapy treatment. A broad differential diagnosis and systemic study are required to rule out entities such as ocular ischemic syndrome and diabetic retinopathy, in addition to early treatment to avoid possible complications.
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Isquemia , Traumatismos por Radiación , Enfermedades de la Retina , Humanos , Femenino , Persona de Mediana Edad , Traumatismos por Radiación/etiología , Traumatismos por Radiación/diagnóstico , Traumatismos por Radiación/complicaciones , Isquemia/etiología , Isquemia/diagnóstico , Diagnóstico Diferencial , Enfermedades de la Retina/etiología , Enfermedades de la Retina/diagnóstico , Síndrome , Angiografía con FluoresceínaRESUMEN
Systemic sclerosis (SSc) is a collagen disease with immune abnormalities, vasculopathy, and fibrosis. Ca blockers and prostaglandins are used to treat peripheral circulatory disturbances. Chronic limb-threatening ischemia (CLTI) is a disease characterized by extremity ulcers, necrosis, and pain due to limb ischemia. Since only a few patients present with coexistence of CLTI and SSc, the treatment outcomes of revascularization in these cases are unknown. In this study, we evaluated the clinical characteristics and treatment outcomes of seven patients with CLTI and SSc, and 35 patients with uncomplicated CLTI who were hospitalized from 2012 to 2022. A higher proportion of patients with uncomplicated CLTI had diabetes and male. There were no significant differences in the age at which ischemic ulceration occurred, other comorbidities, or in treatments, including antimicrobial agents, revascularization and amputation, improvement of pain, and the survival time from ulcer onset between the two subgroups. EVT or amputation was performed in six or two of the seven patients with CLTI and SSc, respectively. Among those who underwent EVT, 33% (2/6) achieved epithelialization and 67% (4/6) experienced pain relief. These results suggest that the revascularization in cases with CLTI and SSc should consider factors such as infection and general condition, since revascularization improve the pain of these patients.
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Isquemia Crónica que Amenaza las Extremidades , Esclerodermia Sistémica , Humanos , Masculino , Femenino , Esclerodermia Sistémica/complicaciones , Esclerodermia Sistémica/terapia , Anciano , Persona de Mediana Edad , Resultado del Tratamiento , Isquemia Crónica que Amenaza las Extremidades/cirugía , Isquemia Crónica que Amenaza las Extremidades/complicaciones , Isquemia Crónica que Amenaza las Extremidades/etiología , Isquemia Crónica que Amenaza las Extremidades/diagnóstico , Isquemia Crónica que Amenaza las Extremidades/terapia , Amputación Quirúrgica/estadística & datos numéricos , Procedimientos Endovasculares , Estudios Retrospectivos , Isquemia/etiología , Isquemia/terapia , Isquemia/diagnóstico , Anciano de 80 o más Años , AdultoRESUMEN
Chronic limb threatening ischemia (CLTI) is the most severe manifestation of peripheral arterial disease and represents a particularly high-risk subgroup of patients. As such, efforts to better understand this complex patient population through well-designed clinical research studies are critical to improving CLTI care. Prospective randomized clinical trials (RCTs) remain the gold standard in clinical research, but these trials are resource-intensive and have highly selective patient populations, which limit their feasibility and generalizability. Alternatively, retrospective studies are less expensive than RCTs, have a larger sample size, and are more generalizable owing to a broader patient population. Health care administrative data provide rich sources of information that may be used for research purposes and are increasingly being used for the study of vascular surgery conditions, including CLTI. Although administrative data are collected for billing purposes, they may be leveraged to study a broad range of topics in vascular surgery including those related to health care delivery, epidemiology, health disparities, and outcomes. This review provides an overview of administrative data available for CLTI research, the strengths and limitations of these data sources, current areas of investigation, and future opportunities for further study with the goal of improving outcomes in this high-risk population.
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Isquemia Crónica que Amenaza las Extremidades , Enfermedad Arterial Periférica , Humanos , Resultado del Tratamiento , Isquemia Crónica que Amenaza las Extremidades/cirugía , Isquemia Crónica que Amenaza las Extremidades/terapia , Isquemia Crónica que Amenaza las Extremidades/epidemiología , Enfermedad Arterial Periférica/terapia , Enfermedad Arterial Periférica/diagnóstico , Bases de Datos Factuales , Factores de Riesgo , Procedimientos Quirúrgicos Vasculares , Reclamos Administrativos en el Cuidado de la Salud , Isquemia/terapia , Isquemia/diagnóstico , Isquemia/epidemiología , Enfermedad CrónicaRESUMEN
BACKGROUND: The heparin-bonded expanded polytetrafluoroethylene (He-ePTFE) conduit is an option for patients requiring infrainguinal revascularization (iIR), but the risk of failure may be unpredictable, especially in cases with poor run-off. Intraoperative transit-time flow (TTF) provides an automated and quantitative analysis of flow and may serve as an adjunct evaluation during surgical revascularization. The aim of this study was to assess TTF in patients undergoing iIR with He-PTFE at 3 referral hospitals and to establish a predictive flow threshold for graft occlusion. METHODS: A prospective registry initiated in 2020 enrolled patients undergoing iIR using He-PTFE for critical limb ischemia or severe claudication, and TTF measurement was analyzed. Preoperative assessments of anatomical and clinical characteristics were available for all patients. The HT353 Optima Meter (Transonic Systems Inc., Ithaca, NY, USA) was used in all procedures according to a standardized protocol. The institutional ethics committee approved the study. A predictive model using receiver operating characteristic curve analysis was utilized to establish the threshold of flow, and variables were compared. Anatomical and clinical evaluation were reported according to Rutherford grade, Global Limb Anatomic System and Wound, Ischemia, and foot Infection classification. The main outcome considered was the correlation between TTF and graft occlusion. Secondary outcomes included survival, other predictors of graft occlusion, freedom from major adverse cardiovascular events, and freedom from major amputation. RESULTS: Among 68 patients, 55.8% had Rutherford 5-6, 45.6% had Global Limb Anatomic System 3 and 73.5% had Wound, Ischemia, and foot Infection 3-4. Distal anastomosis was at tibial level in 23.5% and mean diameter of conduit was 6.4 mm. Basal and postoperative TTF were 27.8 ± 15.6 ml/min and 109.0 ± 53.0 ml/min, respectively. After a mean follow-up of 18 ± 13 months, 7 (10.9%) patients presented graft occlusion and 5 (7.8%) required major amputation. TTF threshold = 80 ml/min revealed a sensitivity and specificity of 81.8% (95% confidence interval 48.2-97.7) and 80.7% (95% confidence interval 68.1-90.0) respectively, and it was selected as cut-off for graft occlusion. Freedom from graft occlusion in patients with TTF >80 ml/min vs. TTF ≤80 ml/min at 6, 12, and 24 months was 95.7% (standard error (SE) = 0.030) vs. 65.5% (SE = 0.115), 95.7% (SE = 0.030) vs. 58.9% (SE = 0.120) and 90.9% (SE = 0.054) vs. 51.6% (SE = 0.126), P = 0.0003. No statistical difference in primary patency, secondary patency and limb salvage was observed. At multivariate analysis, distal anastomosis at tibial vessel (odds ratio 8.50) and TTF ≤80 ml/min (odds ratio 9.39) were independent predictors of graft occlusion. CONCLUSIONS: These results suggest that TTF may serve as a valuable tool in the management of iIR. A TTF measurement of ≤80 ml/min should be regarded as a predictor of graft occlusion, prompting consideration of additional intraoperative maneuvers to enhance arterial flow. Caution should be exercised in patients requiring direct tibial artery revascularization, as it represents a predictor of failure independent of TTF levels. Larger cohorts of patients and longer follow-up periods are necessary to confirm these findings.
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Implantación de Prótesis Vascular , Prótesis Vascular , Oclusión de Injerto Vascular , Heparina , Isquemia , Enfermedad Arterial Periférica , Politetrafluoroetileno , Valor Predictivo de las Pruebas , Diseño de Prótesis , Flujo Sanguíneo Regional , Sistema de Registros , Grado de Desobstrucción Vascular , Humanos , Masculino , Femenino , Anciano , Estudios Prospectivos , Implantación de Prótesis Vascular/instrumentación , Implantación de Prótesis Vascular/efectos adversos , Heparina/administración & dosificación , Heparina/efectos adversos , Enfermedad Arterial Periférica/fisiopatología , Enfermedad Arterial Periférica/cirugía , Enfermedad Arterial Periférica/diagnóstico por imagen , Factores de Tiempo , Factores de Riesgo , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/fisiopatología , Isquemia/fisiopatología , Isquemia/cirugía , Isquemia/diagnóstico , Isquemia/diagnóstico por imagen , Persona de Mediana Edad , Anciano de 80 o más Años , Velocidad del Flujo Sanguíneo , Materiales Biocompatibles Revestidos , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Enfermedad Crítica , Recuperación del Miembro , Insuficiencia del Tratamiento , Amputación Quirúrgica , Medición de Riesgo , Claudicación Intermitente/fisiopatología , Claudicación Intermitente/cirugía , Claudicación Intermitente/diagnóstico por imagen , Claudicación Intermitente/diagnósticoRESUMEN
BACKGROUND: Pedal arch interrogation by ultrasound through systolic acceleration time measurement (Pedal Acceleration Time [PAT]) is a recently described technique that offers valuable insights into foot hemodynamics. Previous studies have demonstrated a correlation between PAT and the ankle-brachial index and PAT has been proposed as a prognostic tool for wound healing in patients with peripheral artery disease. This study aims to assess the correlation between PAT and Transcutaneous Pressure of Oxygen (TcPO2) in the diabetic foot population. METHODS: In this single-center cross-sectional study PAT and TcPO2 were measured in diabetic patients with ischemic foot ulcers. The assessment of wound status was performed between the 12th and 16th week after the first evaluation. The primary outcome was to assess the correlation between the values obtained for PAT and TcPO2. The secondary outcome was to establish a cut-off value for wound healing. RESULTS: Sixty limbs with ischemic foot ulcers were evaluated. The results showed a correlation between PAT and TcPO2 [F (1.52) = 16.928; R2 = 0.246; P < 0.001]. The receiver operating characteristics curve analysis showed an optimal cut-off value at PAT >186 ms for predicting a nonhealing ulcer with a 96% specificity (area under the curve = 0.774; confidence interval 0.648-0.872; P < 0.001). CONCLUSIONS: PAT showed a significant correlation with TcPO2 with high specificity to identify nonhealing foot ulcers due to insufficient foot perfusion with a potential prognostic value in the diabetic foot population.
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Monitoreo de Gas Sanguíneo Transcutáneo , Pie Diabético , Valor Predictivo de las Pruebas , Cicatrización de Heridas , Humanos , Pie Diabético/fisiopatología , Pie Diabético/diagnóstico , Pie Diabético/terapia , Masculino , Femenino , Estudios Transversales , Anciano , Persona de Mediana Edad , Factores de Tiempo , Pie/irrigación sanguínea , Oxígeno/sangre , Flujo Sanguíneo Regional , Isquemia/fisiopatología , Isquemia/diagnóstico por imagen , Isquemia/diagnóstico , Isquemia/terapia , HemodinámicaRESUMEN
BACKGROUND: Inflammation is a key element in the initiation and progression of peripheral arterial disease (PAD). Understanding the impact of inflammatory molecules, as cytokines in PAD could help us to improve the prognosis of these patients. The main goal of this study was to compare the serum level of cytokines between patients with claudication to those with chronic limb-threatening ischemia (CLTI). The second objective was to evaluate the relationship between the levels of cytokines and death or amputation rate. METHODS: An observational, single-center, and prospective study was conducted from January 2018 to July 2022. The study was approved by the ethical commission of the Local Hospital (75/2017). Patients with PAD, suggested by the clinical history and objective examination and confirmed with ankle-brachial index, attending vascular surgery consultations of the first author were included. The following exclusion criteria were applied: i) bedridden individuals or subjects who refused to participate in the protocol; ii) diseases responsible for body composition changes or proinflammatory state; iii) recent diet change, iv) active malignancy, v) autoimmune disease, vi) active infection, vii) chronic renal failure (glomerular filtration rate <30 mL/min/1.73 m2), or viii) heart failure in the past 3 months. This cohort was observed at admission, 3, 6, and 12 months. A panel of 27 cytokines was determined with ELISA, at baseline. RESULTS: We included 119 subjects (mean age: 67.58 ± 9.60 years old; 79.80% males), 65 patients with claudication and 54 with CLTI. From the 27 cytokines analyzed, patients with CLTI, when compared to those with claudication, had a higher serum level of 11 cytokines: IL1ra, IL-6, IL-8, IL12 p70, G-CSF, IP-10, MCP-1, MIP-1α, PDGF-ß, RANTES, and TNF-α. From the group of patients with CLTI those who underwent a major amputation had a higher serum level of FGF-basic [median = 49.04; interquartile range = 37.03-52.49; versus median = 33.04; interquartile range = 28.60-38.98; P = 0.001]. CONCLUSIONS: Patients with CLTI have higher serum level of inflammatory cytokines, which may have role in the prognosis of these patients.
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Amputación Quirúrgica , Biomarcadores , Citocinas , Mediadores de Inflamación , Claudicación Intermitente , Enfermedad Arterial Periférica , Humanos , Masculino , Citocinas/sangre , Anciano , Femenino , Estudios Prospectivos , Enfermedad Arterial Periférica/sangre , Enfermedad Arterial Periférica/diagnóstico , Biomarcadores/sangre , Persona de Mediana Edad , Mediadores de Inflamación/sangre , Claudicación Intermitente/sangre , Claudicación Intermitente/diagnóstico , Claudicación Intermitente/fisiopatología , Claudicación Intermitente/inmunología , Factores de Tiempo , Isquemia Crónica que Amenaza las Extremidades/sangre , Isquemia Crónica que Amenaza las Extremidades/cirugía , Regulación hacia Arriba , Anciano de 80 o más Años , Factores de Riesgo , Recuperación del Miembro , Isquemia/sangre , Isquemia/diagnósticoRESUMEN
This case highlights a rare presentation of diverticulitis of the sigmoid colon with perforation into the retroperitoneum complicated by abscess, vertebral osteomyelitis and acute lower extremity ischemia. A late 40-year-old man presented to an emergency department with acute ischemia of his left lower extremity. He was tachycardic with a leucocytosis, an unremarkable abdominal exam and a pulseless, insensate and paralysed left lower extremity. Imaging revealed sigmoid thickening, an abscess adjacent to iliac vasculature and occlusion of the left popliteal artery. The abscess came in contact with prior spine anterior lumbar interbody fusion (ALIF) hardware at L5-S1 vertebrae. The patient was taken urgently to the operating room for embolectomy, thrombectomy and fasciotomy. He was started on antibiotics and later underwent operative drainage with debridement for osteomyelitis. Non-operative management of the complicated diverticulitis failed, necessitating open sigmoidectomy with colostomy. 1 year later, he was symptom-free and the colostomy was reversed.