PTFE Bypass or Thrupass for Superficial Femoral Artery Occlusion? A Randomised Controlled Trial

AbstractEarly results of a thrupass endograft in the treatment of femoral lesions are promising. Less morbidity and better cost-effectiveness are suggested to be achieved in the treatment of chronic lower limb ischaemia with endovascular treatment compared to surgical treatment.Patients and methodsThis randomised multicentre trial aimed to enroll a group of 60+60 patients for the treatment of 5–25-cm occlusions of superficial femoral artery (SFA) to be followed up for 3 years. Patients were treated either with endoluminal PTFE thrupass (WL Gore & Ass) or with surgical polytetrafluoroethylene (PTFE) bypass to proximal popliteal artery. Primary patency at 3 years was scheduled to be the primary end-point and secondary patency, functional success, costs and quality of life the secondary end-points.ResultsA sample of 100 consecutive SFA occlusions in one of the centres revealed that only 4% of the lesions were amenable for the study. The trial was prematurely terminated due to the results of an interim analysis at the time when 44 patients were recruited: the 1-year primary patency (excluding technical failures) was 48% for thrupass and 95% for bypass (p=0.02). The patency difference in favour of surgical bypass over endovascular thrupass was also sustained after completion of 1-year follow-up, the primary patencies being 46% and 84% at 1 year with grossly equilinear life-table curves thereafter (p=0.18), respectively. The corresponding secondary patencies were 63% and 100% (p=0.05) when excluding technical failures and 58% and 100% (p=0.02) according to intention-to-treat analysis. Secondary outcomes were thus not analysed.ConclusionTreatment of SFA occlusions (TASC IIB and C or Imelda Ia and II) should be done by PTFE bypass rather than by PTFE thrupass, as thrupass is connected with worse early outcome. These results represent only a small category of femoral disease

Adjuncts to improve neurological outcome following hypothermic circulatory arrest:an experimental study using a chronic porcine model

Abstract Interruption of cerebral blood flow during hypothermic circulatory arrest (HCA) predisposes neurons to glutamate excitotoxicity. Reperfusion is followed by leukocyte infiltration, which results in an inflammatory reaction in the brain tissue. In the first study, the presynaptic glutamate release inhibitor lamotrigine (L) and the leukocyte-depleting filter (LF) were studied to determine if their combination could mitigate brain injury after HCA (I). The aim of the second study was to evaluate the possible neuroprotective effect of a 14-hour period of mild (32°C) hypothermia after HCA (II). Recent experimental research has demonstrated the neuroprotective properties of erythropoietin (EPO) and fructose-1,6-bisphosphate (FDP), whose effects during and after HCA were evaluated in the third and the fourth studies (III, IV). A chronic porcine model was used. The animals were randomly assigned to the study groups as follows: 8 animals in the L+LF group, 8 in the L group, and 8 in the control group (I); 10 animals in the hypothermia group and 10 in the normothermia group (II); 10 animals in the EPO group and 10 in the control group (III), and 12 animals in the FDP group and 12 in the control group (IV). Monitoring of hemodynamics, metabolism, temperature, electroencephalogram (EEG), brain microdialysis, intracranial pressure (II-IV), and brain tissue oxygen (II-IV) was carried out. A daily behavioral assessment was performed until death or until elective sacrifice on the seventh postoperative day, after which the brain was prepared for a histopathologic examination. The results of these studies indicate that lamotrigine has a neuroprotective effect during HCA. This is observed in terms of EEG burst recovery, behavioral and histopathologic outcome, and brain microdialytic findings. The combined use of lamotrigine and leukocyte filtration may further improve survival. A 14-hour period of mild hypothermia after HCA is associated with a poor outcome. However, it may preserve its efficacy when used for no longer than 4 hours. Administration of EPO before HCA proved ineffective in reducing mortality or brain histopathologic injury. Findings from brain microdialysis, brain tissue oxygen tension, and neuronal apoptosis, however, suggest that the drug has neuroprotective properties. Administration of FDP before and after HCA is associated with better survival, behavioral outcome, and brain histopathologic scores. The metabolic and brain microdialytic findings also suggest that this drug has supportive effects on myocardial and brain metabolism

A case of acute aortoiliac occlusive disease presenting as cauda equina syndrome and Fournier’s gangrene

Abstract Aortoiliac occlusive disease presents itself more frequently as chronic claudication, erectile dysfunction, and absent femoral pulses. Its acute manifestation is less frequently encountered in a clinical practice; hence, it presents sometimes as a diagnostic challenge. We illustrate a case of acute aortoiliac occlusive disease presenting with spinal cord ischemia and gluteal and scrotal necroses, which was initially diagnosed and treated as spinal cord compression. In order to avoid misdiagnosis, careful examination of peripheral pulses of both lower limbs should always be part of the initial evaluation of cauda syndrome and paraplegia and when Fournier’s gangrene is suspected

Staged Endovascular Stent-grafting and Surgical Treatment of a Secondary Aortoduodenal Fistula

AbstractSecondary aortoenteric fistula is a dramatic, rather infrequent late complication occurring mostly after abdominal aortic surgery. Currently, graft excision and in situ bypass is considered the treatment of choice, but it is associated with significant mortality and morbidity. Herein, we describe the case of a secondary aortoduodenal fistula treated by staged endovascular stent-grafting and surgical closure of the fistula. Forty days after stent-grafting, Tc-99m-HMPAO labelled leukocyte scanning failed to identify leukocyte infiltration of the graft and there were no clinical signs of infection. At 8-month follow up, the patient was asymptomatic

Photoplethysmographic measurements on clinical patients (>65 y) and healthy cohorts between ages of 18—75 y

Abstract The biomedical information on different indexes like arterial elasticity index (AEI), arterial age (AA) is used in many cases. However, they applicability for diseases earlier prediction like arteriosclerosis (AS) is seldom applied. Many illnesses are becoming common, especially cardiovascular disorders (CVD) among elderly people, and in females. It is predicted that the negative impacts of AS on young people can be greater than on the elderly people in the long run because of sedentary lifestyle. Degenerative changes in the arteries have many causes in addition to the lifestyle. Arterial elasticity (AE) would provide a direct indicator for cardiovascular healthiness and predict AS. AE can be challenging in the cases of elderly, but also in the case of the young persons whose endothelial functions have been earlier very good. The vessel properties would be important to know for characterization of both arterial diseases and the development of reliable devices. Photoplethysmography (PPG), and especially its response pulse wave decomposition, envelope analysis, and its second order derivative (SDPPG) open the new health information for clinics. PPG signals are correlated with the alterations in blood pressure, blood flow, arterial elasticity, and health indexes. Exposure of human to physical exercise has been shown to improve endothelial function in patients with risk factors and heart failure. Exercise has been shown to be protective to cardiovascular disease. In addition according to this study, the exact mathematical solution for the pulse wave analysis has be replaced by numerical analysis method. In addition, a probability density function and a coherence function suits well to the inherent resting PPG process, and giving some intrinsic properties of the arterial pulsation phenomena

Short-term stability of combined finger and toe photoplethysmogram analysis

Arterial pulse waves (PWs) provide information on the vascular health and could be utilized in the early detection of atherosclerosis. The aim of the study is to characterize the short-term repeatability of combined finger and toe photoplethysmographic (PPG) signal analysis method which we call finger-toe plot (FT-plot) and compare it with other methods proposed for vascular characterization. PPG signals were recorded from 24 atherosclerotic and 47 control subjects from finger and toe. The repeatability of the method was analyzed by means of intra-class correlation coefficients (ICC) and free-marginal multirater κ agreement. The metrics were computed for individual PWs as well as for averages based on 10–100 PWs. The ICCs increased with number of PWs utilized — ICCs and κ agreements higher than ≥ 0.90 were widely achieved based on the averages of ≥ 20 PWs, depending on the parameter or study group. Based on the present results, the FT-plot based detection of atherosclerotic changes has at least equal repeatability compared with a current clinical standard, ankle-to-brachial pressure index. However, further studies should validate the findings before the method is ready for the screening of atherosclerotic changes.acceptedVersionPeer reviewe

Effects of percutaneous transluminal angioplasty of superficial femoral artery on photoplethysmographic pulse transit times

Abstract We analyze the changes in upper and lower limb pulse transit times (PTT) caused by peripheral artery disease (PAD) and its treatment with percutaneous transluminal angioplasty (PTA) of the superficial femoral artery. PTTs were extracted from the photoplethysmograms (PPG) recorded from an index finger and 2nd toes. PTTs were defined between the R-peaks of the ECG and different reference points of the PPG: foot and peak points, maxima of 1st and 2nd derivative, and by means of intersecting tangents method. Also the PTTs between the toe and finger pulses were analyzed. Our sample consists of 24 subjects examined before and after the PTA and in 1-month followup visit. Also 28 older than 65 years controls having normal ankle-to-brachial pressure index (ABI) and no history in cardiovascular diseases as well as 21 younger subjects were examined. The differences between the groups and preand post-treatment phases were analyzed by means of non-parametric statistical tests. The changes in the PTTs of upper limb and non-treated lower limb were negligible. The agreement with the reference values, ABI and toe pressures, was studied by kappa-analysis, resulting in kappa-values of 0.33–0.91. Differences in PTTs were found between pretreatment state of the treated limb, post-treatment state and the follow-up visit, as well as between the pre-treatment state and controls. If patients’ age and systolic blood pressure were taken into consideration, the method of lower limb PTT calculation from the peak point turns out feasible in finding the markers of PAD and monitoring post-treatment vascular remodellation

Next-generation sequencing in a large pedigree segregating visceral artery aneurysms suggests potential role of COL4A1/COL4A2 in disease etiology

Abstract Background: Visceral artery aneurysms (VAAs) can be fatal if ruptured. Although a relatively rare incident, it holds a contemporary mortality rate of approximately 12%. VAAs have multiple possible causes, one of which is genetic predisposition. Here, we present a striking family with seven individuals affected by VAAs, and one individual affected by a visceral artery pseudoaneurysm. Methods: We exome sequenced the affected family members and the parents of the proband to find a possible underlying genetic defect. As exome sequencing did not reveal any feasible protein-coding variants, we combined whole-genome sequencing of two individuals with linkage analysis to find a plausible non-coding culprit variant. Variants were ranked by the deep learning framework DeepSEA. Results: Two of seven top-ranking variants, NC_000013.11:g.108154659C>T and NC_000013.11:g.110409638C>T, were found in all VAA-affected individuals, but not in the individual affected by the pseudoaneurysm. The second variant is in a candidate cis-regulatory element in the fourth intron of COL4A2, proximal to COL4A1. Conclusions: As type IV collagens are essential for the stability and integrity of the vascular basement membrane and involved in vascular disease, we conclude that COL4A1 and COL4A2 are strong candidates for VAA susceptibility genes