Long-term results after percutaneous transluminal angioplasty of the subclavian artery

Wstęp. Zespół podkradania tętnicy podobojczykowej jest istotnym problemem klinicznym, w którym przewlekłe niedokrwienie kończyny górnej może powodować zaburzenia ukrwienia mózgu. Obecnie postępowaniem z wyboru w przypadku całkowitej niedrożności tętnicy podobojczykowej jest leczenie chirurgiczne, natomiast w przypadkach zwężeń stosuje się techniki śródnaczyniowe. Materiał i metody. W klinice, w której pracują autorzy, w latach 1989–1998 u 74 chorych (44 kobiet i 30 mężczyzn w wieku 20–71 lat; średnio 49 lat) wykonano przezskórną dylatację (PTA, percutaneous transluminal angioplasty) z powodu zwężenia tętnicy podobojczykowej. Dobre wyniki angioplastyki uzyskano u 69 chorych (93,2%). Zgody na ponowne wykonanie zabiegów nie wyraziło 5 pacjentów (8,1%), u których doszło do szybkiego nawrotu zwężenia. Celem pracy była analiza odległych wyników PTA u 52 chorych w okresie 16–128 miesięcy (średnio 51 miesięcy) od wykonanego zabiegu. Wyniki. U 39 (75%) chorych odnotowano poprawę stanu klinicznego potwierdzoną badaniem duplex-doppler,a także zrównanie wartości ciśnienia tętniczego na tętnicach ramiennych. U żadnego z pacjentów nie stwierdzono objawów przewlekłego niedokrwienia mózgu lub kończyny górnej. W tym okresie u 8 chorych obserwowano nawrót zwężenia tętnicy podobojczykowej. Ocena morfologiczna wykazała poniżej 50-procentowe zwężenia światła naczynia, powodujące różnice ciśnienia krwi na tętnicy ramiennej poniżej 20 mm Hg.Introduction. Subclavian steal syndrome is a clinical problem of great importance, in which chronic upper limb ischaemia can cause a deficit of blood supply to the brain. Nowadays surgery is the routine approach to the management of complete subclavian artery (SA) occlusion; in the case of stenosis endovascular procedure is preferable. Material and methods. We treated 74 patients with percutaneous transluminal angioplasty (PTA) for SA stenosis in our Department in the years 1989–1998 (44 females, 30 male; age 20–71 years, mean 49 years). Good results after angioplasty were obtained in 69 patients (93.2%). Five patients (8.1%) had only a temporary improvement but they refused further procedures. Analysis of the long-term results after SA PTA was the aim of the study. Fifty-two patients were followed-up for 16 to 128 months (mean 51 months). Results. Thirty-nine patients (75%) had clinical improvement and normal vertebral artery blood flow direction confirmed by duplex-doppler, as well as equal brachial pressures. None of the patients complained of any signs of chronic brain or hand ischaemia. During follow-up 8 patients (15.4%) were diagnosed with subclavian artery stenosis, however lesser than 50%, causing a difference of brachial pressure up to 20 mm Hg

Standards of the Polish Ultrasound Society. Ultrasound examination of the portal system and hepatic vessels

Increased incidence of liver diseases, the development of liver surgery and other invasive methods for managing portal hypertension, plus an increasing number of liver transplant procedures pose more and more new challenges for ultrasonography. Ultrasonography, being an effective and clinically verified modality, has been used for several decades for diagnosing diseases of the liver, its vessels and portal hypertension. It is used for both initial and specialist diagnosis (performed in reference centers). The diagnostic value of ultrasonography largely depends on the knowledge of anatomy, physiology, pathophysiology and clinical aspects as well as on the mastering of the scanning technique. In the hands of an experienced physician, it is an accurate and highly effective diagnostic tool; it is of little use otherwise. The paper presents elements of anatomy, physiology and pathophysiology which make the portal system exceptional and the knowledge of which is crucial and indispensable for a correct examination and, above all, for the correct interpretation of results. The authors also present requirements regarding the equipment. Moreover, various technical aspects of the examination are presented and the normal morphological picture and hemodynamic parameters of healthy individuals are described. The authors discuss the most common clinical situations and rare cases during ultrasound examinations. The paper is based on the experience of the author who works in the largest center of liver diseases in Poland, and on the current literature.Wzrost zachorowań na choroby wątroby oraz rozwój chirurgii wątroby i innych inwazyjnych metod leczenia nadciśnienia wrotnego, a także zwiększająca się liczba zabiegów transplantacji wątroby wyznaczają wciąż nowe wyzwania dla ultrasonografii. Ultrasonografia, jako skuteczna i sprawdzona klinicznie metoda, stosowana jest od kilku dekad w diagnostyce chorób wątroby, jej naczyń i nadciśnienia wrotnego. Wykorzystywana jest zarówno na poziomie diagnostyki wstępnej, jak i specjalistycznej – wykonywanej w ośrodkach referencyjnych. Wartość diagnostyczna ultrasonografii w dużym stopniu zależy od znajomości anatomii, fizjologii, patofizjologii i aspektów klinicznych, a także stopnia opanowania techniki badania. W rękach doświadczonego lekarza metoda ta jest precyzyjnym i bardzo skutecznym narzędziem diagnostycznym, w przeciwnym razie jest bezużyteczna. W opracowaniu omówiono podstawowe elementy anatomii, fizjologii i patofizjologii, które stanowią o wyjątkowości układu wrotnego, a których znajomość jest kluczowa i niezbędna dla prawidłowego wykonania badania, a przede wszystkim właściwej interpretacji wyników. Przedstawiono wymagania dotyczące zaawansowania wykorzystywanej aparatury. Omówiono różne techniczne aspekty badania oraz prawidłowy obraz morfologiczny i parametry hemodynamiczne u osób zdrowych, a także najczęstsze sytuacje kliniczne i związane z nimi odchylenia od norm w wykonywanych badaniach. Prezentowana praca oparta jest na kilkunastoletnim doświadczeniu autora pracującego w największym ośrodku chirurgii wątroby w Polsce oraz na podstawie aktualnego piśmiennictwa

Standards of the Polish Ultrasound Society – update. Ultrasound examination of the visceral arteries

Ultrasound examination is a valuable method in diagnosing visceral vasoconstriction of atherosclerotic origin, as well as constriction related to the compression of the celiac trunk. Given the standard stenosis recognition criteria of >70%, the increase in peak systolic velocity (PSV) over 200 cm/s in the celiac trunk; of PSV > 275 cm/s in the superior mesenteric artery, and of PSV > 250 cm/s in the inferior mesenteric artery, the likelihood of correct diagnosis is above 90%. In the case of stenosis due to compression of the celiac trunk by median arcuate ligament of the diaphragm, a valuable addition to the regular examination procedure is to normalize the flow velocity in the vessel, i.e. the reduction in peak systolic velocity levels below 200 cm/s, and in end-diastolic velocity (EDV) levels below 55 cm/s during deep inspiration. In the case of celiac trunk stenosis exceeding 70–80%, additional information on the level of collateral circulation can be obtained by measuring the flow in the hepatic and splenic arteries – assessing the flow velocity, resistance, and pulsatility indices (which fall below 0.65 and below 1.0 in cases of stenosis of the celiac trunk with a reduced capacity of collateral circulation), as well as assessing the changes in these parameters during normal respiration and during inspiration. This paper discusses in detail the examination methods for the celiac trunk and mesenteric arteries, as well as additional procedures used to confi rm the diagnosis and pathologies affecting visceral blood flow velocity, i.e.: cirrhosis and hypersplenism. The publication is an update of the Polish Ultrasound Society guidelines published in 2011

Standards of the Polish Ultrasound Society. Ultrasound examination of the portal system and hepatic vessels

Increased incidence of liver diseases, the development of liver surgery and other invasive methods for managing portal hypertension, plus an increasing number of liver transplant procedures pose more and more new challenges for ultrasonography. Ultrasonography,being an effective and clinically verifi ed modality, has been used for several decades for diagnosing diseases of the liver, its vessels and portal hypertension. It is used for both initial and specialist diagnosis (performed in reference centers). The diagnostic value of ultrasonography largely depends on the knowledge of anatomy, physiology, pathophysiology and clinical aspects as well as on the mastering of the scanning technique. In the hands of an experienced physician, it is an accurate and highly effective diagnostic tool;it is of little use otherwise. The paper presents elements of anatomy, physiology and pathophysiology which make the portal system exceptional and the knowledge of which is crucial and indispensable for a correct examination and, above all, for the correct interpretation of results. The authors also present requirements regarding the equipment. Moreover,various technical aspects of the examination are presented and the normal morphological picture and hemodynamic parameters of healthy individuals are described. The authors discuss the most common clinical situations and rare cases during ultrasound examinations.The paper is based on the experience of the author who works in the largest center of liver diseases in Poland, and on the current literature

Volumetric Flow Assessment in Doppler Ultrasonography in Risk Stratification of Patients with Internal Carotid Stenosis and Occlusion

(1) Background: Alterations of blood flow volume in extracranial arteries may be related to the risk of occurrence of neurological symptoms. The aim of this study was the estimation of cerebral blood flow (CBF) in Doppler ultrasonography, as well as comparison of the flow volume in asymptomatic patients over 65 years old with ≥50%, and symptomatic patients with ≥70% internal carotid artery (ICA) stenosis, in order to assess whether the changes in the CBF correlates with the presence of neurological symptoms. (2) Methods: 308 patients over 65 years old were included in the retrospective cohort observational study: 154 asymptomatic with ≥50% ICA stenosis, 123 healthy volunteers, and 31 symptomatic referred for surgical treatment. The study group was split according to ICA stenosis (50–69%, 70–99% and occlusion). In all patients an extensive Doppler ultrasound examination with measurements of flow volume in common, internal, external carotid (ECA) and vertebral arteries (VA) was performed. (3) Results: Among asymptomatic (A) and symptomatic (S) patients with carotid stenosis 3 subgroups were identified: 57/154—37% (A) and 8/31—25.5% (S)—with significantly increased flow volume (CBF higher than reference range: average CBF + std. dev in the group of healthy volunteers), 67/154—43.5% (A) and 12/31—39% (S)—with similar to reference group flow volume (CBF within range average ± std.dev), and 30/154—19.5% (A) and 11/31—35.5% (S)—with decreased flow volume in extracranial arteries (flow lower than average-std.dev. in healthy volunteers). In symptomatic patients the percentage of patients with significant compensatory increased flow tends to raise with the severity of the stenosis, while simultaneous decline of number of patients with mild compensation (unchanged total CBF) is observed. The percentage of patients without compensation remains unchanged. In the group referred for surgical treatment (symptomatic, ≥70% ICA stenosis) the percentage of patients with flow compensation is twice as low as in the asymptomatic ones with similar degree of the ICA stenosis (8/31—25.8% vs. 26/53—49%, p = 0.04). Compensatory elevated flow was observed most frequently in ECA. (4) Conclusions: The presence of significant volumetric flow compensation has protective influence on developing ischaemic symptoms, including TIA or stroke. The assessment of cerebral inflow in Doppler ultrasonography may provide novel and easily accessible tool of identifying patients prone to cerebral ischaemia. The multivessel character of compensation with enhanced role of ECA justifies the importance of including this artery in the estimation of CBF

Choroba kociego pazura – diagnostyka i leczenie

Choroba kociego pazura (cat scratch disease – CSD) jest rzadkorozpoznawaną chorobą bakteryjną o różnym obrazie klinicznym.Najczęściej przebiega w postaci miejscowej limfadenopatii, u ok.50% pacjentów może wywoływać objawy choroby rozrostowej,w pojedynczych przypadkach mogą wystąpić objawy ze stronyukładu mięśniowo-szkieletowego: zapalenie kości, artropatia lubmialgia.W pracy przedstawiono opis bardzo wcześnie zdiagnozowanej klinicznie,potwierdzonej laboratoryjnie na podstawie badań serologicznychi molekularnych CSD u 10-letniego chłopca.Pierwsze objawy w postaci powiększenia węzłów chłonnych zaobserwowanopo 2–3 tygodniach od zadrapania okolicy lewego barkuprzez kota. W badaniu USG stwierdzono powiększenie, obrzęki przekrwienie węzłów chłonnych lewego ramienia i przedramienia.W 11. dobie wystąpiła gorączka o torze hektycznym. Zmianyw wynikach badań laboratoryjnych – przyspieszony OB i leukocytoza– pojawiły się dopiero w 14. dobie, w 21. dobie zaobserwowanozwiększenie stężenia białka C-reaktywnego (C-reactive protein– CRP). Wyniki pozostałych badań były w normie przez cały czastrwania choroby.Pomimo terapii cefetamet pivoxil rozpoczętej w 10. dobie choroby,w 16. dobie wytworzył się ropień w pobliżu węzła chłonnego okolicyłokciowej. Zmiany ustąpiły całkowicie po zabiegu chirurgicznymi zastosowaniu netylmycyny

Intracranial Flow Volume Estimation in Patients with Internal Carotid Artery Occlusion

(1) Background: Carotid artery occlusion (CAO) in population studies has a reported prevalence of about 6 per 100,000 people; however, the data may be underestimated. CAO carries a significant risk of stroke. Up to 15% of large artery infractions may be secondary to the CAO, and in 27–38% of patients, ischaemic stroke is a first presentation of the disease. The presence of sufficient and well-developed collateral circulation has a protective influence, being a good prognostic factor in patients with carotid artery disease, both chronic and acute. Understanding the mechanisms and role of collateral circulation may be very important in the risk stratification of such patients. (2) Materials and Methods: This study included 46 patients (mean age: 70.5 ± 6 years old; 15 female, mean age 68.5 ± 3.8 years old and 31 male, mean age 71.5 ± 6.7 years old) with unilateral or bilateral ICA occlusion. In all patients, a Doppler ultrasound (DUS) examination, measuring blood flow volume in the internal carotid artery (ICA), external carotid artery (ECA), and vertebral artery (VA), was performed. The cerebral blood flow (CBF) was compared to the previously reported CBF values in the healthy population >65 years old. (3) Results: In comparison with CBF values in the healthy population, three subgroups with CBF changes were identified among patients with ICA occlusion: patients with significant volumetric flow compensation (CBF higher than average + standard deviation for healthy population of the same age), patients with flow similar to the healthy population (average ± standard deviation), and patients without compensation (CBF lower than the average-standard deviation for healthy population). The percentage of patients with significant volumetric flow compensation tend to rise with increasing age, while a simultaneous decline was observed in the group without compensation. The percentage of patients with flow similar to the healthy population remained relatively unchanged. ICA played the most important role in volumetric flow compensation in patients with CAO; however, the relative increase in flow in the ICA was smaller than that in the ECA and VA. Compensatory increased flow was observed in about 50% of all patent extracranial arteries and was more frequently observed in ipsilateral vessels than in contralateral ones, in both the ECA and the VA. In patients with CAO, there was no decrease in CBF, ICA, ECA, and VA flow volume with increasing age. (4) Conclusions: Volumetric flow compensation may play an important predictive role in patients with CAO