The efficacy and safety of closure of brachial access using the AngioSeal closure device: Experience with 161 interventions in diabetic patients with critical limb ischemia

PurposeThis study retrospectively evaluated the efficacy and safety of the 6F Angio-Seal (St. Jude Medical, St. Paul, Minn) as a closure device for transbrachial artery access for endovascular procedures in diabetic patients with critical limb ischemia.MethodsFrom January 2005 and September 2007, 1887 diabetic patients underwent interventional procedures in the lower limbs at a two diabetic foot centers. Patients presented with rest pain (16%), ulcers (80%), or gangrene (4%). Systemic anticoagulation with sodium heparin (70 IU/kg) was obtained for all patients at the beginning of the endovascular treatment. A total of 249 brachial arteries (238 patients) were evaluated for possible Angio-Seal use after endovascular recanalization of the leg. Color Doppler ultrasound imaging of the artery was obtained before revascularization only in patients with previous Angio-Seal placement in the brachial artery. No further imaging studies were done in the remaining brachial arteries where the Angio-Seal was deployed at the operator’s discretion. Impairment or disappearance of the radial pulse or onsets of hand ischemia or hand pain, or impairment of hand function during or at the end of the endovascular revascularization were all regarded as contraindications to Angio-Seal usage. Evidence of a highly calcified plaque of the brachial artery access site at the time of vessel puncture was regarded as an absolute contraindication to the Angio-Seal use. Patients were seen before discharge, at 1, 3, and 8 weeks after the procedure, and at 3-month intervals thereafter. Complications included hemorrhage, pseudoaneurysm, infection, and vessel occlusion.ResultsA total of 1947 Angio-Seal collagen plugs were deployed in 1709 diabetic patients (90.5%). The Angio-Seal was used for brachial artery closure in 159 patients (8.4%) in 161 procedures (159 in the left, 2 in the right brachial artery). In 79 patients (4.2%) in 88 procedures (87 in the left and 1 in the right brachial artery), the device was deemed contraindicated due to small vessel size in 73 patients (92.4%) or presence of calcium at the access site in five patients (6.3%). One patient (1.3%) refused the collagen plug closure after revascularization. The non-Angio-Seal group was evaluated for comparison. The success rate for achieving hemostasis in the Angio-Seal group was 96.9%. Five major complications (3.1%) at 30 days consisted of two puncture site hematomas >4 cm, two brachial artery occlusions, and one brachial artery pseudoaneurysm, with three patients requiring open surgery. Minor complications (7.50%) were three puncture site hematomas < 4 cm, three oozing of blood from the access site, and six patients had mild pain in the cubital fossa. No further complications were recorded in the 14-month follow-up (range 1-25 months) of a total of 140 patients.ConclusionsThis retrospective study shows that the 6F Angio-Seal is a valuable and safe vascular closure device for transbrachial access in diabetic patients undergoing interventional procedures for critical limb ischemia

Mechanism of reductive elimination of 1,1,1-trifluoroethane from cis-hydrido(2,2,2-trifluoroethyl)bis(triphenylphosphine)platinum(II)

Mechanism of reductive elimination of 1,1,1-trifluoroethane from cis-hydrido(2,2,2-trifluoroethyl)bis(triphenylphosphine)platinum(II)

Aritmie da deglutizione. [Arrhythmias from swallowing].

Abstract We describe the case of a 51-year old, non cardiopathic patient, with recurrent attacks of supraventricular tachycardia induced by swallowing. In the existing literature we found several descriptions of hypokinetic arrhythmias, easily explained by a mechanism of vagal inhibition. The cases of predominantly hyperkinetic arrhythmias, however, are much less common. In these patients the origin of the disease seems to be due to sympathetic oesophageal fibers and superior and medium cardiac nerves. In the present case, as in the others reported in the literature, the drug of choice seems to be Amiodarone which appears to be the most effective in preventing tachyarrhythmias caused by swallowin

[Heart involvement in Behcet's disease: a personal caseload en review of the literature].

Abstract BACKGROUNDS: Various cardiac abnormalities have been described in patients with Behçet's disease. The number of reports remains small, but increasing awareness have widened the spectrum of manifestations. We report our evaluation of cardiac involvement in 15 patients affected by Behçet's disease, diagnosed according to the criteria for the International Study Group for Behçet's Disease. PATIENTS AND METHODS: All the patients have been examined by a clinical, biochemical and instrumental point of view. Six patients resulted to be affected by heart diseases, in particular by mitral valve prolapse; moreover one of them presented an unexpected dilatative cardiomyopathy. CONCLUSIONS: The authors affirm that the pathological heart features are not so uncommon as previously reported in literature, emphasizing the necessity of a constant evaluation for the cardiovascular system also in the asymptomatic patients

Migratory activity of circulating mononuclear cells is associated with cardiovascular mortality in type 2 diabetic patients with critical limb ischemia

OBJECTIVE Prediction of clinical outcome in diabetic patients with critical limb ischemia (CLI) is unsatisfactory. This prospective study investigates if the abundance and migratory activity of a subpopulation of circulating mononuclear cells, namely, CD45dimCD34posCXCR4posKDRpos cells, predict major amputation and cardiovascular death in type 2 diabetic patients undergoing percutaneous transluminal angioplasty for CLI. RESEARCH DESIGN AND METHODS A consecutive series of 119 type 2 diabetic patients with CLI was enrolled. CD45dimCD34posCXCR4posKDRpos cells were assessed by flow cytometry upon isolation and also after spontaneous or stromal cell-derived factor 1α−directed migration in an in vitro assay. The association between basal cell counts and migratory activity and the risk of an event at 18-month follow-up was evaluated in a multivariable regression analysis. RESULTS Time-to-event analysis of amputation (n = 13) showed no association with the candidate predictors. Sixteen cardiovascular deaths occurred during 18 months of follow-up. Abundance of CD45dimCD34posCXCR4posKDRpos cells was not associated with cardiovascular mortality. Interestingly, in vitro migration of CD45dimCD34posCXCR4posKDRpos cells was higher in patients with cardiovascular death compared with event-free subjects (percentage of migrated cells median value and interquartile range, 0.03 [0.02–0.07] vs. 0.01 [0.01–0.03]; P = 0.0095). Multivariable regression model analysis showed that cell migration forecasts cardiovascular mortality independently of other validated predictors, such as age, diagnosed coronary artery disease, serum C-reactive protein, and estimated glomerular filtration rate. In this model, doubling of migrated cell counts increases the cardiovascular death hazard by 100% (P &lt; 0.0001). CONCLUSIONS The new predictor could aid in the identification of high-risk patients with type 2 diabetes requiring special diagnostic and therapeutic care after revascularization

Soluble ST2 is regulated by p75 neurotrophin receptor and predicts mortality in diabetic patients with critical limb ischemia

&lt;b&gt;Objective—&lt;/b&gt;&lt;p&gt;&lt;/p&gt; The p75 neurotrophin receptor (p75&lt;sup&gt;NTR&lt;/sup&gt;) contributes to diabetes mellitus−induced defective postischemic neovascularization. The interleukin-33 receptor ST2 is expressed as transmembrane (ST2L) and soluble (sST2) isoforms. Here, we studied the following: (1) the impact of p75&lt;sup&gt;NTR&lt;/sup&gt; in the healing of ischemic and diabetic calf wounds; (2) the link between p75&lt;sup&gt;NTR&lt;/sup&gt; and ST2; and (3) circulating sST2 levels in critical limb ischemia (CLI) patients. &lt;p&gt;&lt;/p&gt; &lt;b&gt;Methods and Results—&lt;/b&gt;&lt;p&gt;&lt;/p&gt; Diabetes mellitus was induced in p75&lt;sup&gt;NTR&lt;/sup&gt; knockout (p75KO) mice and wild-type (WT) littermates by streptozotocin. Diabetic and nondiabetic p75KO and WT mice received left limb ischemia induction and a full-thickness wound on the ipsilateral calf. Diabetes mellitus impaired wound closure and angiogenesis and increased ST2 expression in WT, but not in p75KO wounds. In cultured endothelial cells, p75&lt;sup&gt;NTR&lt;/sup&gt; promoted ST2 (both isoforms) expression through p38&lt;sup&gt;MAPK&lt;/sup&gt;/activating transcription factor 2 pathway activation. Next, sST2 was measured in the serum of patients with CLI undergoing either revascularization or limb amputation and in the 2 nondiabetic groups (with CLI or nonischemic individuals). Serum sST2 increased in diabetic patients with CLI and was directly associated with higher mortality at 1 year from revascularization. &lt;p&gt;&lt;/p&gt; &lt;b&gt;Conclusion—&lt;/b&gt;&lt;p&gt;&lt;/p&gt; p75&lt;sup&gt;NTR&lt;/sup&gt; inhibits the healing of ischemic lower limb wounds in diabetes mellitus and promotes ST2 expression. Circulating sST2 predicts mortality in diabetic CLI patients. &lt;p&gt;&lt;/p&gt