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Limb ischemia, acute [keywords]
- Outcome of acute limb ischemia in cancer patients. [JOURNAL ARTICLE]
- Vasc Med 2014 Feb 14.
The optimal management strategy for acute limb ischemia (ALI) in patients with a concomitant malignancy is not well established. A very high mortality rate (83-100%) at 1 year has been reported in those who are treated surgically. Accordingly, a conservative management approach has been suggested as the main therapeutic modality. Our aim was to evaluate the survival outcomes of cancer patients treated for ALI at our cancer center. Cancer patients treated for ALI at the MD Anderson Cancer Center from 2001 to 2011 were included in this study. Overall survival and amputation-free survival rates were calculated. A total of 74 cancer patients with concomitant ALI were included in the study. Surgery was the most common therapy (36 patients; 49%). Percutaneous catheter-based interventions were used in 21 patients (28%). Eighteen patients (24%) received anticoagulation therapy only, and six patients (8%) received no therapy. The 30-day, 6-month, and 1-year overall survival rates were 80% (95% confidence interval [CI], 69% to 87%), 59% (95% CI, 47% to 69%), and 48% (95% CI, 36% to 59%), respectively. Eight patients (11%) underwent amputation. The 1-year amputation-free survival rate was 47% (95% CI, 35% to 58%). In conclusion, we did not find an invasive approach for the treatment of ALI in cancer patients to be associated with the very high mortality rates previously reported. In our opinion, the indications for surgery or catheter-based intervention in these patients should not differ from patients without cancer.
- Hybrid Revascularization Procedures in Acute Limb Ischemia. [JOURNAL ARTICLE]
- Ann Vasc Surg 2014 Feb 11.
Although the clinical efficacy of hybrid procedures in patients with chronic limb ischemia has been well reported in the literature, sufficient evidence is lacking in the acute setting. Our aim was to evaluate the immediate and mid-term clinical results on 28 patients with acute lower limb ischemia treated with hybrid reconstructions on emergent basis, from January 2010 to March 2013 in our tertiary referral vascular centre.Twenty-eight patients (31 operated limbs) underwent emergent hybrid revascularization, with endovascular treatment performed proximally or distally to the site of open reconstruction. The median follow-up period was 6 months (range: 1-26 months). The immediate technical success was clinically and hemodynamically evaluated with ankle-brachial pressure index (ABPI) measurement. Six-month overall patency, limb salvage and survival rate were also estimated. All analyses were performed with the Kaplan-Meier life table method, using the STATISTICA 7.0 statistical program.Twenty seven patients presented with grade IIb and one with grade III ischemia, respectively. Technical success was achieved in all patients whereas hemodynamic improvement rate in 98%. ABPI preoperatively was increased from 0.14±0.1 to 0.69±0.28 post-operatively (p <0.05). Perioperative morbidity and mortality rates were 21% and 11% respectively. 6-month overall patency, limb salvage and survival rate was 86%, 92% and 79%, respectively.Hybrid revascularization in immediately threatened limbs provides an effective and durable option with acceptable mortality and amputation rate in these high-risk patients. These findings should be further confirmed by larger-scale clinical studies.
- Dual gene transfer of bFGF and PDGF in a single plasmid for the treatment of myocardial infarction. [JOURNAL ARTICLE]
- Exp Ther Med 2014 Mar; 7(3):691-696.
Basic fibroblast growth factor (bFGF) and platelet-derived growth factor (PDGF) have been shown to be involved in a spectrum of cellular processes. In a previous study, we constructed a novel multigenic vector that contained two separate transcription units, each consisting of a strong promoter and an efficient polyadenylation signal. The two promoters were chosen for their ability to work simultaneously. Dual gene transfer of bFGF and PDGF in a single plasmid resulted in a significant increase in collateral blood vessel formation in a rabbit model of hind limb ischemia. The aim of the present study was to investigate the effect of this dual gene transfer strategy in a rat model of acute myocardial infarction (AMI). AMI was induced in rats by ligation of the left anterior descending coronary artery. The animals were randomly divided into four groups and treated with the following therapeutic strategies: Empty plasmid (control), plasmid encoding bFGF (PL-bFGF), plasmid encoding PDGF (PL-PDGF) or plasmid encoding bFGF and PDGF (PL-F-P). Echocardiography and histological examinations were performed 28 days subsequent to gene transfer. Dual gene therapy with bFGF and PDGF resulted in a significant angiogenic effect accompanied by vessel maturation, along with a significant reduction in infarct size and improvement in cardiac function. In a rat model of AMI, single plasmid-mediated dual gene therapy with bFGF and PDGF decreased infarct size and improved cardiac function due to the formation of functionally and morphologically mature vasculature. These results are relevant to the ongoing clinical trials involving the use of single plasmid-mediated angiogenic factors for the treatment of myocardial ischemic disease.
- Posttraumatic Axillary False Aneurysm after Luxatio Erecta of the Shoulder: Case Report and Literature Review. [JOURNAL ARTICLE]
- Ann Vasc Surg 2014 Feb 5.
Vascular complications after dislocation of the shoulder are rare. We report a case of glenohumeral inferior dislocation (luxatio erecta) responsible for an acute ischemia of the upper limb. Endovascular treatment with a covered stent associated with the evacuation of the compressive hematoma was privileged. In the second stage, an axillary bypass was carried out because of an intrastent thrombosis responsible for an acute ischemia of the right upper limb. The stabilization of the glenohumeral articulation was obtained later with an anterior coracoid bone block. The conventional surgical treatment remains the standard treatment. Hybrid techniques with endovascular clamping can be useful in the presence of proximal arterial lesions. Endovascular treatment is an interesting therapeutic alternative in the urgency and in selected cases but its mid- and long-term results should still be evaluated.
- Aortoiliac Occlusive Disease Presenting as Sudden Onset Paraplegia. [JOURNAL ARTICLE]
- Ann Vasc Surg 2014 Feb 5.
Thromboembolism and atherosclerotic stenosis both can cause arterial occlusion. Aortoiliac occlusive disease involving bifurcation of the aortoiliac artery induces symptoms of ischemia such as claudication and pain of buttocks and thighs, decreased bilateral femoral pulses, and impotence. Here, we describe a 58-year-old woman with a past history of atrial fibrillation and lacuna stroke with minimal right side weakness. She presented to our emergency department with sudden onset bilateral pain in the legs and paraplegia. A comprehensive examination revealed paresthesia and decreasing bilateral distal pulses. Computed tomographic imaging showed filling defects over the low abdominal aorta just above the bifurcation of the common iliac artery and bilateral femoral arteries. Acute aortic embolic occlusion was suspected. Her symptoms were resolved after emergent thrombectomy for acute limb ischemia. Physicians need to be aware of aortoiliac embolic occlusive disease which may present as acute paraplegia.
- Successful endovascular repair of an unusual right-to-left shunt presenting with cerebral ischemia. [JOURNAL ARTICLE]
- J Clin Neurosci 2013 Dec 13.
Ischemic stroke due to congenital cardiopulmonary vasculature anomalies is rare in adults. We report a 54-year-old man with a stroke due to a unique right-to-left shunt who underwent successful endovascular treatment. This patient developed acute onset of right arm weakness with facial droop and aphasia which improved after intravenous thrombolysis. An MRI showed acute cerebral ischemia in the left middle cerebral artery and left posterior cerebral artery distribution. The patient developed recurrent stroke symptoms during agitated saline injection while undergoing a transthoracic echocardiogram which showed right-to-left shunting. Chest CT scan and conventional angiography revealed near occlusion of the superior vena cava. Head and upper limb venous return drained via a large left vertical vein into an anomalous left pulmonary vein into the left atrium. He underwent endovascular surgery to relieve the superior vena cava obstruction and to occlude the source of right-to-left shunt. While rare, congenital cardiopulmonary vascular anomalies may result in ischemic stroke in adults. CT angiography may be necessary to evaluate cardiopulmonary vasculature when right-to-left shunting is discovered on echocardiography in the setting of ischemic stroke. With large right-to-left shunts, agitated saline should be avoided.
- The cytokine midkine supports neutrophil trafficking during acute inflammation by promoting adhesion via β2 integrins (CD11/CD18). [Journal Article]
- Blood 2014 Mar 20; 123(12):1887-96.
Emerging evidence suggests a role of the cytokine midkine (MK) in inflammation. In this study, its functional relevance for recruitment of polymorphonuclear neutrophils (PMNs) during acute inflammation was investigated. Intravital microscopy and histologic analysis of tumor necrosis factor-α-stimulated cremaster muscle venules revealed severely compromised leukocyte adhesion and extravasation in MK(-/-) mice compared with MK(+/+) animals. Systemic administration of recombinant MK completely rescued the adhesion defect in MK(-/-) mice. In a hind limb ischemia model, leukocyte accumulation in MK(-/-) mice was significantly diminished compared with MK(+/+) animals. However, MK did not lead to an inflammatory activation of PMNs or endothelial cells suggesting that it does not serve as classical proinflammatory cytokine. Unexpectedly, immobilized MK mediated PMN adhesion under static and flow conditions, whereas PMN-derived MK was dispensable for the induction of adhesion. Furthermore, adhesion strengthening remained unaffected by MK. Flow cytometry revealed that immobilized, but not soluble MK, significantly promoted the high affinity conformation of β2 integrins of PMNs. Blocking studies of low-density lipoprotein receptor-related protein 1 (LRP1) suggested that LRP1 may act as a receptor for MK on PMNs. Thus, MK seems to support PMN adhesion by promoting the high affinity conformation of β2 integrins, thereby facilitating PMN trafficking during acute inflammation.
- Muscle fiber viability, a novel method for the fast detection of ischemic muscle injury in rats. [Journal Article]
- PLoS One 2014; 9(1):e84783.
Acute lower extremity ischemia is a limb- and life-threatening clinical problem. Rapid detection of the degree of injury is crucial, however at present there are no exact diagnostic tests available to achieve this purpose. Our goal was to examine a novel technique - which has the potential to accurately assess the degree of ischemic muscle injury within a short period of time - in a clinically relevant rodent model. Male Wistar rats were exposed to 4, 6, 8 and 9 hours of bilateral lower limb ischemia induced by the occlusion of the infrarenal aorta. Additional animals underwent 8 and 9 hours of ischemia followed by 2 hours of reperfusion to examine the effects of revascularization. Muscle samples were collected from the left anterior tibial muscle for viability assessment. The degree of muscle damage (muscle fiber viability) was assessed by morphometric evaluation of NADH-tetrazolium reductase reaction on frozen sections. Right hind limbs were perfusion-fixed with paraformaldehyde and glutaraldehyde for light and electron microscopic examinations. Muscle fiber viability decreased progressively over the time of ischemia, with significant differences found between the consecutive times. High correlation was detected between the length of ischemia and the values of muscle fiber viability. After reperfusion, viability showed significant reduction in the 8-hour-ischemia and 2-hour-reperfusion group compared to the 8-hour-ischemia-only group, and decreased further after 9 hours of ischemia and 2 hours of reperfusion. Light- and electron microscopic findings correlated strongly with the values of muscle fiber viability: lesser viability values represented higher degree of ultrastructural injury while similar viability results corresponded to similar morphological injury. Muscle fiber viability was capable of accurately determining the degree of muscle injury in our rat model. Our method might therefore be useful in clinical settings in the diagnostics of acute ischemic muscle injury.
- EKOS™ ultrasound - accelerated catheter - directed thrombolysis for acutely occluded femoro-popliteal graft. [Journal Article]
- Cardiovasc Revasc Med 2014 Jan; 15(1):43-5.
Acute limb ischemia due to bypass thrombotic occlusion may occur in patients with poor collateral circulation. It constitutes a medical emergency with increased morbidity, mortality and risk for limb amputation. Although the management of acute limb ischemia due to native artery occlusion is well studied, the optimal approach of acute bypass graft failure resulting in acute limb ischemia is uncertain. We present a case of acute limb ischemia in a patient with femoro-femoral and femoro-popliteal graft who presented with acute limb ischemia due to acute thrombotic occlusion of his femoro-popliteal graft. The patient was successfully managed with ultrasound-enhanced catheter-directed thrombolysis using the EkoSonic® endovascular system with excellent clinical and angiographic results. To our knowledge this is the first published report of the use of the EkoSonic® system for this indication.
- A Deceitful Case of Spinal Cord Malperfusion Presented as an Acute Limb Ischemia. [JOURNAL ARTICLE]
- Ann Vasc Surg 2014 Jan 16.
We present an interesting case of a patient with spinal cord ischemia presented with physical and angiographic findings of acute right leg ischemia 6 days after abdominal aortic aneurysm open repair. After unsuccessful transpopliteal thrombectomy, patient was treated with spinal cord drainage. Cause of this complication might be ischemic lumbal plexopathy.