Oxidized low-density lipoprotein and ankle-brachial pressure index in patients with clinically evident peripheral arterial disease

OBJECTIVES: To investigate whether oxidized low-density lipoprotein is a suitable predictor of peripheral arterial disease severity. The role of oxidized low-density lipoprotein in the pathogenesis of atherosclerosis has already been investigated. Its relevance as a predictor of the appearance and worsening of coronary arterial disease is also well known. However, the same is not true regarding peripheral arterial disease. METHOD: Eighty-five consecutive patients with an ankle-brachial pressure index (ABPI) < 0.9 and the presence of either intermittent claudication or critical lower leg ischemia were included. The plasma level of IgG autoantibodies against oxidized low-density lipoprotein was evaluated through an enzyme-linked immunosorbent assay. The results were categorized into quartiles according to the ankle-brachial pressure index (a marker of peripheral arterial disease severity), and significant differences were investigated with the Kruskal-Wallis test. RESULTS: There was no significant difference between the quartiles for this population (p = 0.33). No correlation was found between the ankle-brachial pressure index and oxidized low-density lipoprotein levels in subjects with clinically evident peripheral arterial disease with a wide range of clinical manifestations. CONCLUSIONS: Oxidized low-density lipoprotein is not a good predictor of peripheral arterial disease severity

Agressão externa aos membros inferiores como fator preditivo na evolução dos pacientes submetidos a revascularização arterial

PURPOSE: A variety of predictive factors for the evolution of arterial grafts in patients with critical ischemia have been well defined in clinical studies, including diabetes mellitus, dialytic renal insufficiency, smoking, and distal arterial runoff. The goal of this study was to determine whether patients with critical ischemia undergoing arterial reconstruction in which ischemic lesions appeared spontaneously, compared to those in which the ischemic lesion appeared following an external aggression to the limb present different patterns of evolution. METHODS: From February 2002 to January 2004, 100 patients undergoing infra-inguinal arterial reconstruction were followed. They were divided into 2 groups: 1) the spontaneous group (n = 52), comprising individuals presenting with ischemic lesions of spontaneous origin and 2) the external aggression to the limb group (n = 48), comprising individuals for which an external causal mechanism for the appearance of the ischemic lesion was identified. The variables analyzed were limb salvage and graft functioning rates. RESULTS: Patients with spontaneous lesions had rates of limb salvage and graft functioning significantly lower than those for patients with lesions that were secondary to external aggression (42.3% versus 87.5%, respectively for both outcomes; POBJETIVO: Diversos fatores preditivos de evolução de enxertos arteriais em pacientes com isquemia grave foram definidos em estudos clínicos como diabetes mellitus, insuficiência renal, fumo e vasão distal. O objetivo deste estudo foi verificar se pacientes com isquemia grave submetidos a revascularização nos quais as lesões apareceram espontaneamente apresentam evolução diferente daquela em que as lesões apareceram após uma agressão externa ao membro. MÉTODOS: De fevereiro de 2002 a janeiro de 2004, 100 pacientes submetidos a revascularizações infra-inguinais foram seguidos. Eles foram divididos em 2 grupos: 1) Grupo com lesão espontânea (52 pacientes), que compreendia pacientes apresentando lesões isquêmicas de origem espontânea e 2) Grupo de lesão por agressão externa (48 pacientes) que compreendia pacientes em que um mecanismo externo era identificado como causa do aparecimento da lesão isquêmica. As variáveis analisadas foram salvamento de membro e índices de perviedade dos enxertos. RESULTADOS: Pacientes com lesão espontânea apresentam índices de salvamento de membro e perviedade do enxerto significativamente menores que pacientes com lesões secundárias a agressão externa (42,3% x 87,5%, respectivamente para ambos itens de estudo;

Tratamento endovascular para pacientes portadores de Claudicação Intermitente que não melhoram com tratamento clínico

PURPOSE: To study the results including long-term follow-up obtained with endovascular treatment of patients with intermittent claudication who did not experience clinical improvement with conservative treatment. METHODS: From January 1992 to January 2002, 62 of 1380 patients (4.5%) with intermittent claudication underwent endovascular treatment and were followed up for up to 120 months (mean 76 months). The variables analyzed were the functioning of the arterial segment undergoing the endovascular procedure, the evolution of the maximum walking distance, and incidence of related morbidity and mortality. RESULTS: Fifty-two patients (84%) experienced no walking limitation after the procedure, and 6 patients (10%) improved but still exhibited some degree of limitation, for a total improved outcome of 94%. The patency rate was 82%. There was no intraoperative mortality. One primary failure and one immediate thrombosis occurred, and both were surgically corrected. Thrombosis of the treated artery occurred in 6 patients 12, 16, 25, 29, 62, and 66 months after the procedure. These patients started to experience intermittent claudication with a walking distance to onset that was similar to their presurgical distance to onset. During follow-up, a mortality rate of 12.9% (8 patients) was observed, 6 due to myocardial infarctions and 2 due cerebral infarction. Three patients underwent coronary bypasses 22, 36, and 55 months after the endovascular surgery, and 2 patients underwent coronary angioplasty after 6 and 26 months. The mean follow up period was 76 months (range 0-120 months). CONCLUSION: This study shows that endovascular treatment of intermittent claudication brought about a lasting regression of the ischemic conditions in a significant number of patients, with excellent patency rates. It was concluded that this is a good alternative for selected patients, with low rates of complications and positive long-term results.OBJETIVO: Estudar a longo prazo (média de 76 meses de seguimento) os resultados obtidos com o tratamento endovascular em pacientes que não melhoram com o tratamento clínico, MÉTODOS: De Janeiro de 1992 a Janeiro de 2002, 62 pacientes de um grupo de 1380 claudicantes foram submetidos a tratamento endovascular, representando 4,5% do total. As variáveis analisadas foram o funcionamento do segmento arterial submetido ao procedimento endovascular, a evolução da distância máxima de marcha e a ocorrência de morbi-mortalidade. RESULTADOS: Cinqüenta e dois (84%) pacientes não apresentaram restrições à deambulação após o procedimento. Seis pacientes melhoraram, representando um benefício de 94%. Não houve mortalidade intra-operatória. Uma falência primária e uma trombose imediata foram corrigidas cirurgicamente. Seis pacientes apresentaram trombose da artéria tratada 12, 16, 25, 29, 62 e 66 meses após o procedimento e voltaram a apresentar Claudicação Intermitente para as mesmas distâncias referidas antes da cirurgia. Durante o seguimento foi observada taxa de mortalidade de 12,9% (8 pacientes), dos quais 6 por infarto do miocárdio e dois por acidente vascular cerebral. Três pacientes foram submetidos à revascularização miocárdica 22, 36 e 55 meses após o procedimento endovascular e duas angioplastias foram realizadas com 6 e 26 meses de seguimento. O tempo médio de segmento foi de 76 meses (0 a 120 meses). CONCLUSÃO: O tratamento endovascular da Claudicação Intermitente levou a melhora das condições da marcha em um número significativo de pacientes, com excelentes taxas de patência (82,0%). Concluímos que esta é uma boa alternativa para determinados pacientes, com poucas complicações e resultados positivos a longo prazo

Use of arteriography for the initial evaluation of patients with intermittent lower limb claudication

CONTEXT: Many patients with intermittent claudication continue to be forwarded to the vascular surgeon for initial evaluation after arteriography has already been accomplished. OBJECTIVE: The main objective of this work was to analyze the usefulness and the need for this procedure. TYPE OF STUDY: Retrospective study. SETTING: The patients were divided into two groups: Group 1, with the arteriography already performed and Group 2 without the initial arteriography. PARTICIPANTS: One hundred patients with intermittent claudication were retrospectively studied. Other specialists had forwarded them for the first evaluation of intermittent claudication, without any previous treatment. MAIN MEASUREMENTS: All patients were treated clinically for at least a 6-month period. The total number of arteriographies performed in the two groups was compared and the need and usefulness of the initial arteriography (of Group 1) was also analyzed. RESULTS: The evolution was similar for both groups. The total number of arteriographies was significantly higher in Group 1 (Group 1 with 53 arteriographies vs. Group 2 with 7 arteriographies). For this group, it was found that arteriography was only useful in five cases (10%), because the surgeries were based on their findings. However, even in those cases, no need for arteriography was observed, as the procedure could have been performed at the time of surgical indication. CONCLUSION: There are no indications for arteriography in the early evaluation of patients with intermittent claudication, because it does not modify the initial therapy, independent of its result. In cases where surgical treatment is indicated, this procedure should only be performed prior to surgery

Use of arteriography for the initial evaluation of patients with intermittent lower limb claudication

CONTEXT: Many patients with intermittent claudication continue to be forwarded to the vascular surgeon for initial evaluation after arteriography has already been accomplished. OBJECTIVE: The main objective of this work was to analyze the usefulness and the need for this procedure. TYPE OF STUDY: Retrospective study. SETTING: The patients were divided into two groups: Group 1, with the arteriography already performed and Group 2 without the initial arteriography. PARTICIPANTS: One hundred patients with intermittent claudication were retrospectively studied. Other specialists had forwarded them for the first evaluation of intermittent claudication, without any previous treatment. MAIN MEASUREMENTS: All patients were treated clinically for at least a 6-month period. The total number of arteriographies performed in the two groups was compared and the need and usefulness of the initial arteriography (of Group 1) was also analyzed. RESULTS: The evolution was similar for both groups. The total number of arteriographies was significantly higher in Group 1 (Group 1 with 53 arteriographies vs. Group 2 with 7 arteriographies). For this group, it was found that arteriography was only useful in five cases (10%), because the surgeries were based on their findings. However, even in those cases, no need for arteriography was observed, as the procedure could have been performed at the time of surgical indication. CONCLUSION: There are no indications for arteriography in the early evaluation of patients with intermittent claudication, because it does not modify the initial therapy, independent of its result. In cases where surgical treatment is indicated, this procedure should only be performed prior to surgery

Maintenance treatment of diabetic patients, associating arterial obstructive tibio-peroneal disease

When a melito-diabetic patient presents trophic infected injury on the limb, it is essential an evaluation of the circulatory conditions for therapeutic procedures orientation. In some circumstances, although arterial pulsation is absent, there is no ischemia of tissues. In these cases, the maintenance treatment, with eventual resection of the necrosed and infected tissues may be adopted. Evolution of 70 diabetic patients with trophic injuries on extremities were submitted to a maintenance treatment. Age of patients varied from 28 to 88 years, with an average of 56.8. The most occurrence was verified in women, with 42 cases. Diabetes non-dependant on insuline (type II) was observed in 64 patients (91.5%), being the remaining 6 patients of type I. Diabetic retinopathy was observed in 14 (20%) of the patients, neuropathy in 22 (31%) and nephropathy in 8 patients (11.4%). All the patients presented arterial pulsation until the popliteal region. They were divided in 2 groups, considering trunk arteries of legs: Group I, pervial legs arteries, composed by 48 patients; Group II, occluded legs arteries, with 22 patients. In what refers to the anatomic local of the injuries, patients were classified in three groups: Group A, formed by 32 patients (45.7%), presenting injuries in one or two toes only, without affecting the metatarsic region; Group B, formed by 16 patients (22.9%), trophic injuries affecting the metatarsic region and Group C, formed by 22 patients (31.4%), injuries affecting the calcaneous region. Injuries in both of the groups were caused by mechanical traumatism. Duration of the injury in the inferior member varied from 7 to 48 days, resulting in a 12 days average. Analyzing pervicacity in trunk arterias and evolution of patients, it may be observed that there has been a significantly better result in those with all the pulses present (81.3% x 45.5%)(p0,05)(Table IV)

Endovascular treatment for intermittent claudication in patients who do not improve with clinical treatment

PURPOSE: To study the results including long-term follow-up obtained with endovascular treatment of patients with intermittent claudication who did not experience clinical improvement with conservative treatment. METHODS: From January 1992 to January 2002, 62 of 1380 patients (4.5%) with intermittent claudication underwent endovascular treatment and were followed up for up to 120 months (mean 76 months). The variables analyzed were the functioning of the arterial segment undergoing the endovascular procedure, the evolution of the maximum walking distance, and incidence of related morbidity and mortality. RESULTS: Fifty-two patients (84%) experienced no walking limitation after the procedure, and 6 patients (10%) improved but still exhibited some degree of limitation, for a total improved outcome of 94%. The patency rate was 82%. There was no intraoperative mortality. One primary failure and one immediate thrombosis occurred, and both were surgically corrected. Thrombosis of the treated artery occurred in 6 patients 12, 16, 25, 29, 62, and 66 months after the procedure. These patients started to experience intermittent claudication with a walking distance to onset that was similar to their presurgical distance to onset. During follow-up, a mortality rate of 12.9% (8 patients) was observed, 6 due to myocardial infarctions and 2 due cerebral infarction. Three patients underwent coronary bypasses 22, 36, and 55 months after the endovascular surgery, and 2 patients underwent coronary angioplasty after 6 and 26 months. The mean follow up period was 76 months (range 0-120 months). CONCLUSION: This study shows that endovascular treatment of intermittent claudication brought about a lasting regression of the ischemic conditions in a significant number of patients, with excellent patency rates. It was concluded that this is a good alternative for selected patients, with low rates of complications and positive long-term results

External aggression to the limb as a predictive factor in the evolution of patients undergoing arterial revascularization Agressão externa aos membros inferiores como fator preditivo na evolução dos pacientes submetidos a revascularização arterial

PURPOSE: A variety of predictive factors for the evolution of arterial grafts in patients with critical ischemia have been well defined in clinical studies, including diabetes mellitus, dialytic renal insufficiency, smoking, and distal arterial runoff. The goal of this study was to determine whether patients with critical ischemia undergoing arterial reconstruction in which ischemic lesions appeared spontaneously, compared to those in which the ischemic lesion appeared following an external aggression to the limb present different patterns of evolution. METHODS: From February 2002 to January 2004, 100 patients undergoing infra-inguinal arterial reconstruction were followed. They were divided into 2 groups: 1) the spontaneous group (n = 52), comprising individuals presenting with ischemic lesions of spontaneous origin and 2) the external aggression to the limb group (n = 48), comprising individuals for which an external causal mechanism for the appearance of the ischemic lesion was identified. The variables analyzed were limb salvage and graft functioning rates. RESULTS: Patients with spontaneous lesions had rates of limb salvage and graft functioning significantly lower than those for patients with lesions that were secondary to external aggression (42.3% versus 87.5%, respectively for both outcomes; P <.001). CONCLUSIONS: The absence of an external aggression as a contributing factor to a critical ischemic lesion in the lower limb may result in a poorer evolution of both graft function and limb salvage following arterial revascularization. However, this factor is not expected to directly influence the case conduct, since almost half of the patients without evident external aggression had good graft functioning and limb salvage. This prognostic factor should be used just as all others are, i.e., to give patients and doctors a better idea of the possible evolution in such cases.<br>OBJETIVO: Diversos fatores preditivos de evolução de enxertos arteriais em pacientes com isquemia grave foram definidos em estudos clínicos como diabetes mellitus, insuficiência renal, fumo e vasão distal. O objetivo deste estudo foi verificar se pacientes com isquemia grave submetidos a revascularização nos quais as lesões apareceram espontaneamente apresentam evolução diferente daquela em que as lesões apareceram após uma agressão externa ao membro. MÉTODOS: De fevereiro de 2002 a janeiro de 2004, 100 pacientes submetidos a revascularizações infra-inguinais foram seguidos. Eles foram divididos em 2 grupos: 1) Grupo com lesão espontânea (52 pacientes), que compreendia pacientes apresentando lesões isquêmicas de origem espontânea e 2) Grupo de lesão por agressão externa (48 pacientes) que compreendia pacientes em que um mecanismo externo era identificado como causa do aparecimento da lesão isquêmica. As variáveis analisadas foram salvamento de membro e índices de perviedade dos enxertos. RESULTADOS: Pacientes com lesão espontânea apresentam índices de salvamento de membro e perviedade do enxerto significativamente menores que pacientes com lesões secundárias a agressão externa (42,3% x 87,5%, respectivamente para ambos itens de estudo;p<0,01). CONCLUSÕES: A ausência de agressão externa para o aparecimento de lesões tróficas em membros inferiores isquêmicos é fator prognóstico de pior evolução tanto para o funcionamento dos enxertos como para o salvamento do membro nos pacientes submetidos a revascularizações infra-inguinais. No entanto esse fator não é suficiente para definir uma conduta médica, visto que metade dos pacientes que apresentaram lesão espontânea também tiveram boa evolução. O fator prognóstico deve ser usado como todos os outros - para oferecer aos pacientes e aos médicos uma idéia melhor sobre a possível evolução do caso