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Limb ischemia, acute [keywords]
- A Method of Treating Patients with Acute Type A Aortic Dissection and Lower Extremity Malperfusion. [JOURNAL ARTICLE]
- J Card Surg 2014 Jun 3.
The management of an acute type A aortic dissection in the setting of peripheral vascular malperfusion is not well defined. Several institutions proceed with initial percutaneous intervention to restore end organ perfusion, followed by delayed operative repair of the type A dissection. This strategy is associated with high mortality rates from aortic rupture, myocardial infarction, and stroke. We describe a technique, where acute limb ischemia is concomitantly managed with the replacement of the ascending aorta/hemiarch or aortic arch. In addition to axillary artery cannulation, the ischemic lower extremity is perfused through a polytetrafluoroethylene (PTFE) graft, which is connected to the cardiopulmonary bypass (CPB) circuit.
- Antiplatelet therapy in critical limb ischemia: update on clopidogrel and cilostazol. [JOURNAL ARTICLE]
- J Cardiovasc Surg (Torino) 2014 May 28.
Antiplatelet therapy is essential for CLI patients, both as primary prevention for ischemic events and as adjuvant pharmacotherapy in order to avoid acute or late thrombo-occlusive events and maintain patency following peripheral endovascular or open surgical limb-salvage revascularization procedures. According to currently updated international guidelines clopidogrel as monotherapy or as part of dual antiplatelet therapy is recommended in CLI patients, while recent evidence delineated the beneficial effect of cilostazol in patients undergoing peripheral endovascular angioplasty or stenting as its administration resulted in a decrease of restenosis and clinically-driven reinterventions, as well as in the enhancement of platelet inhibition. This review aims in discussing recent evidence on the topic of antiplatelet therapy in CLI patients, with a special focus on the use of clopidogrel and cilostazol.
- Evaluation of very low amplitude intra-QRS potentials during the initial minutes of acute transmural myocardial ischemia. [JOURNAL ARTICLE]
- J Electrocardiol 2014 Apr 26.
Low-level electrocardiographic changes from depolarization wavefront may accompany acute myocardial ischemia. The purpose of this study was to assess the changes of microvolt amplitude intra-QRS potentials induced by elective percutaneous coronary interventions (PCI).Fifty-seven patients with balloon inflation periods ranging from 3.1 to 7.3minutes (4.9±0.7min) were studied. Nine leads continuous high-resolution ECG before and during PCI were recorded and signal-averaged. Abnormal intra-QRS at microvolt level (μAIQP) were obtained using a signal modeling approach. μAIQP, R-wave amplitude and QRS duration were measured in the processed ECG during baseline and PCI episodes.The mean μAIQP amplitude significantly decreased for each of the standard 12 leads at the PCI event respect to baseline. Left anterior descending artery (LAD) occlusion resulted in a decrease μAIQP in both the precordial leads and the limb leads, while right coronary (RCA) and left circumflex (LCx) arteries occlusions mainly affected limb leads. R-wave amplitude increased during PCI in RCA and LCx groups in lead III but decreased in the precordial leads, while the amplitude decreased in the LAD group in lead III. The average duration of the QRS augmented in groups RCA and LCx but not in the LAD group.Abnormal intra-QRS potentials at the level of μV provide an excellent tool to characterize the very-low amplitude fragmentation of the QRS complex and its changes due to ischemic injuries. μAIQP shows promise as a new ECG index to measure electrophysiologic changes associated with acute myocardial ischemia.
- [Efficacy of short-term catheter-directed thrombolysis used with rt-PA combined with endovascular interventional therapy in patients with lower limb ischemia]. [English Abstract, Journal Article]
- Zhonghua Yi Xue Za Zhi 2014 Apr; 94(13):1017-20.
To evaluate the performance effect of short-term catheter-directed thrombolysis with different dosage of rt-PA allied with endovascular interventional therapy for patients with acute lower limb ischemia.To separate 84 consecutive patients suffered from acute lower limb ischemia into two groups at random, then adopt catheter-directed thrombolysis for each group of patients injected 20 mg (Group A) or 10 mg (Group B) rt-PA into the occlusive lesion correspondingly, and subsequently perform endovascular intervention on significant underlying lesions on the base of angiography results. Adopt statistical methods to assess treatment effectiveness, rates of complication and amputation rates within 30 days, 6 months or 12 months. The statistic analysis was performed under SPSS 16.0 format, and adopts t test and χ(2) test.There was no statistical difference on patient characteristics and lesions between both groups (P > 0.05). Procedural success rates as well clinical success rates were all 100%. Not incur any diversity on thrombolysis effectiveness between both groups injected different dosage of rt-PA (P > 0.05). Not found major differences on ratios of PTA or implant stent between both groups (P > 0.05). During the follow-up period of 30-day, 6-, 12- months, there were no statistical differences on the amputation-free survival rates and complication rates between both groups.Whereas short-term catheter-directed thrombolysis combined with endovascular interventional therapy won good operation effectiveness on patients with acute lower limb ischemia, moreover the dosage of rt-PA did not impact on thrombolysis, it is worthy to be applied in the clinical practice.
- Dissection of left iliac artery during anterior lumbar interspace fusion: Report of a case. [JOURNAL ARTICLE]
- Vascular 2014 May 21.
Vascular injury is an uncommon complication of spine surgery. Among the different approaches, anterior lumbar interbody fusion has increased potential for vascular injuries, since the great vessels and their branches overly the disc spaces to be operated on, and retraction of these vessels is necessary to gain adequate surgical exposure. The reported incidence for anterior lumbar interbody fusion-associated vascular injuries ranges from 0% to 18.1%, with venous laceration as the most common type. We report a case of anterior lumbar interbody fusion-associated left common iliac artery dissection leading to delayed acute limb ischemia developing in early post-operative period.
- Acute limb ischemia in cancer patients: Aggressive treatment is justified. [JOURNAL ARTICLE]
- Vascular 2014 May 21.
The outcome of cancer patients with acute limb ischemia (ALI) is not well defined. The purpose of this study is to report our experience treating patients with active malignancy who developed ALI and compare their outcome with non-cancer patients.A retrospective review of patients treated for ALI between 2009 and 2012 with ALI. We identified those patients who suffered from ALI and compared the outcome of those with active malignancy to those without malignancy.Of 147 patients treated for ALI (122 lower extremity, 25 upper extremity), 24 (16%) were cancer patients. Mean follow-up was 9.8 months for the malignancy group and 13.4 months for the control. Perioperative mortality rates were similar among cancer and non-cancer patients (20% vs. 16%, respectively, NS). Freedom from major amputation at 30 months was similar (95% vs. 89%, NS). Long-term survival rates of cancer patients were significantly lower compared to non-cancer patients (45% vs. 77% respectively, P < 0.05).Treatment of ALI among cancer patients can be achieved with perioperative mortality and limb salvage rates comparable to non-cancer patients. Aggressive treatment is justified when treating cancer patients with ALI.
- Racial disparity in early graft failure after infrainguinal bypass. [JOURNAL ARTICLE]
- J Surg Res 2014 Apr 21.
Racial disparities have been shown to be associated with increasing health-care costs. We sought to identify racial disparities in 30-d graft failure rates after infrainguinal bypass in an effort to define targets for improved health care among minorities.The 2005-2011 National Surgical Quality Improvement Program database was queried for patients with peripheral arterial disease who underwent infrainguinal bypass as their primary procedure. A bivariate analysis was done to assess pre and intraoperative risk factors across race (whites, blacks, and Hispanics). Multivariate logistic regression was performed to assess the independent association of race with 30-d graft failure.Of a total of 16,276 patients, 12,536 (77.0%) were whites, 2940 (18.1%) blacks, and 800 (4.9%) Hispanics. Black patients were more likely to be younger, female, current smokers, and on dialysis (P < 0.001, all). In addition, whites were less likely to present with critical limb ischemia compared with blacks and Hispanics (44.2 versus 55.4 versus 52.8%, respectively; P < 0.001). Similarly, fewer whites underwent femoral-tibial (31.4 vs. 34.7 vs. 38.6% respectively) or popliteal-tibial level bypasses (8.9 versus 13.4 versus 16.1%, respectively) than blacks and Hispanics (P < 0.001, all). There was no difference in the use of autogenous conduit across the groups (P = 0.266). Proportionally more blacks than whites developed early graft failure (6.7 versus 4.5%; P < 0.001) but there was no difference comparing Hispanics to whites (6.0 versus 4.5%; P = 0.057). On multivariable analysis, black race remained independently associated with early graft failure (adjusted odds ratio = 1.26, 95% confidence interval 1.05-1.51; P = 0.011).More blacks and Hispanics present with critical limb ischemia, requiring distal revascularization. Even when controlling for anatomic differences and degree of peripheral arterial disease, black race remained independently associated with early graft failure after infrainguinal bypass. These results identify a target for improved outcomes.
- The challenge of diagnosing the acute non traumatic tetraplegia of a healthy young woman. [JOURNAL ARTICLE]
- Int J Neurosci 2014 May 15.:1-16.
Abstract Acute nontraumatic myelopathies include vascular etiologies most commonly caused by atherosclerotic vascular disease. Other causes that have been reported to occur with varying frequencies include thrombosis,embolism of thrombi and tumor,arteritis,hypotension,dissecting aortic aneurysm,sickle cell disease,intervertebral disk herniation,vertebral body subluxation and iatrogenic causes,usually angiography or surgery. In case of acutely progressing spinal cord syndromes,the diagnosis often given is of transverse myelitis or unknown cause of infarction. Fibrocartilaginous embolism (FCE)is possible cause of spinal ischemia due to embolization of nucleus pulposus fragments through retrograde spinal artery flow. A young woman after intensive exercise developed profound weakness of her upper extremities,progressing to flaccid quadriplegia with sensory level from C3 dermatome. Magnetic resonance imaging (MRI)showed linear hyperintense intramedullary lesion from C2 to Th2 confined to anterior horn area,with typical"owl's eye" appearance. Although exact mechanism of patient's neurological syndrome remains undetermined,we suspected a cord infarction due to FCE related to her vigorous physical exercise.
- Postconditioning Protects Skeletal Muscle Against a Long-Lasting Vascular Occlusion. [JOURNAL ARTICLE]
- J Invest Surg 2014 May 15.
ABSTRACT Purpose/Aim of the Study: Long-lasting lower limb arterial occlusion is a condition with high incidence and complication rates. With the absence of appropriate treatment to cure advanced complications, mortality rates are high. Postconditioning (PC) might be capable of limiting the degree of ischemic-reperfusion (IR) injuries, thus reducing complications and mortality rates. The aim of this study was to evaluate the impact of postconditioning during the first postoperative day on skeletal muscle after a long-lasting arterial occlusion. Materials and Methods: Male Wistar rats (n = 72) underwent 8 hr of infrarenal aortic occlusion followed by 2, 6, 12, or 24 hr of reperfusion. In one group of each reperfusion period, postconditioning was applied. Muscle samples were collected for histological examinations. Furthermore, muscle fiber viability and muscle wet-to-dry ratio were assessed. Blood samples were taken for creatine-kinase measurements. Results: Postconditioning strongly reduced morphological injury compared to the corresponding ischemic-reperfusion group (p < .001). Serum creatine-kinase levels showed a peak at 6 hr post-ischemia (IR: 6702.2 ± 797.5; PC: 5523.3 ± 769.3 IU/l) and decreased to normal level by the end of the experiment (Sham: 171.5 ± 71.6; IR: 186.2 ± 82.7; PC: 174.2 ± 72.4 IU/l). Creatine-kinase levels were significantly reduced by postconditioning (p2hr = .028; p6hr = .06; p12hr = .042). A marked decrease in viability was observed in the ischemic-reperfusion groups (2 hr: 11.0 ± 4.1; 6 hr: 10.3 ± 3.6; 12 hr: 9.4 ± 3.3; 24 hr: 8.6 ± 2.8%), whereas with postconditioning, viability was preserved (2 hr: 26.4 ± 5.5; 6 hr: 24.6 ± 4.5; 12 hr: 24.5 ± 6.8; 24 hr: 26.2 ± 6.1%; p < .001); moreover, a significant decrease in the wet-to-dry ratio was achieved (p < .001). Conclusion: Postconditioning was able to reduce local complications after a long-lasting lower limb vascular occlusion.
Compartment syndrome is a fairly common condition noted in patients with fractures or crush injuries to the extremities(acute compartment syndrome) and in athletes (chronic compartment syndrome). Compartments bound by fascia are found in the extremities, buttocks, and abdomen; conditions that cause intracompartmental swelling and hypertension can lead to ischemia and limb loss. This article reviews diagnosis of the problem, monitoring of compartment pressure, and appropriate treatment.