Showing papers in "International Angiology in 2008"

Indications for compression therapy in venous and lymphatic disease consensus based on experimental data and scientific evidence. Under the auspices of the IUP.

Abstract: Aim The aim of this study was to review published literature concerning the use of compression treatments in the management of venous and lymphatic diseases and establish where reliable evidence exists to justify the use of medical compression and where further research is required to address areas of uncertainty. Methods The authors searched medical literature databases and reviewed their own collections of papers, monographs and books for papers providing information about the effects of compression and randomized clinical trials of compression devices. Papers were classified in accordance with the recommendations of the GRADE group to categorize their scientific reliability. Further classification was made according to the particular clinical problem that was addressed in the papers. The review included papers on compression stockings, bandages and intermittent pneumatic compression devices. Results The International Compression Club met once in Vienna and corresponded by email in order to reach an agreement of how the data should be interpreted. A wide range of compression levels was reported to be effective. Low levels of compression 10-30 mmHg applied by stockings are effective in the management of telangiectases after sclerotherapy, varicose veins in pregnancy, the prevention of edema and deep vein thrombosis (DVT). High levels of compression produced by bandaging and strong compression stockings (30-40 mmHg) are effective at healing leg ulcers and preventing progression of post-thrombotic syndrome as well as in the management of lymphedema. In some areas no reliable evidence was available to permit recommendations of level of compression or duration of treatment. These included: management of varicose veins to prevent progression, following surgical treatment or sclerotherapy for varicose veins, and the level of compression required to treat acute DVT. Conclusion This review shows that whilst good evidence for the use of compression is available in some clinical indications, there is much still to be discovered. Little is know about dosimetry in compression, for how long and at what level compression should be applied. The differing effects of elastic and short-stretch compression are also little understood.

Monocytes contribute to the atherosclerotic cap by transformation into fibrocytes

Abstract: Aim The stability of an atherosclerotic plaque is a key-determining factor in the clinical outcome of cardiovascular disease. In this respect, smooth muscle (SM) alfa actin positive cells play an important role in maintaining plaque stability through formation of a fibrous cap. Recent evidence suggests that circulating progenitors may be a source of these cells. We hypothesized that they may be fibrocytes bone-marrow derived cells that acquire SM-like characteristics, including the expression of SM alfa actin. Methods We examined human carotid endarterectomy specimens for the presence of fibrocytes by immunohistochemistry staining for CD34/procollagen I and leukocyte specific protein-1/procollagen I) and examined fibrocyte differentiation in vitro. Results Fibrocytes were found in regions of plaque growth/healing. They possessed a SM-like spindle shape, produced collagen, and consistent with being fibrocytes they co-localized with transformation growth factor beta, but not serum amyloid P factors, known to promote and inhibit their formation, respectively. While fibrocytes were detected in regions of new growth in 35/40 specimens, only 1/3 of the specimens expressed the SM cell marker calponin, and smoothelin was absent, in these regions. Conclusion Our results demonstrate that fibrocytes contribute to formation of the fibrous cap. With fibrocytes being a monocyte derived cell, we suggest that monocytes may play a more crucial role in the clinical outcome of atherosclerosis than previously realized as they not only contribute directly to plaque instability (through foam cell formation), but also promote plaque stability by transformation into a fibrocyte.

Inflammation in venous disease.

Abstract: Chronic venous disease (CVD), mainly due to venous reflux or, sometimes, to venous outflow obstruction, produces a microcirculatory overload leading to the impairment of venous drainage. Venous drainage depends primarily on a major hemodynamic parameter called trans-mural pressure (TMP). TMP is increased in patients affected by CVD, leading to impaired tissue drainage, and, consequently, facilitating the beginning of the inflammatory cascade. Increased TMP determines red blood cell extravasation and either dermal hemosiderin deposits or iron laden-phagocytes. Iron deposits are readily visible in the legs of all patients affected by severe CVD. Local iron overload could generate free radicals or activate a proteolytic hyperactivity of metalloproteinases (MMPs) and/or downregulate tissue inhibitors of MMPs. These negative effects are particularly evident in carriers of the common HFE gene's mutations C282Y and H63D, because intracellular iron deposits of mutated macrophages have less stability than those of the wild type, inducing a significant oxidative stress. It has been demonstrated that such genetic variants increase the risk of ulcers and advance the age of ulcer onset, respectively. The iron-dependent vision of inflammation in CVD paves the way to new therapeutic strategies including the deliberate induction of iron deficiency as a treatment modality for non-healing and/or recurrent venous leg ulcers. The inflammatory cascade in CVD shares several aspects with that activated in the course of multiple sclerosis, an inflammatory and neurodegenerative disease of unknown origin in which the impairment of cerebral venous outflow mechanisms has been recently demonstrated.

Supplemental surgical treatment to end stage (stage IV-V) of chronic lymphedema.

Abstract: Aim When the lymphedema reaches to its end stages, the complex decongestive therapy (CDT) and/or compression therapy become less effective and increased risk of systemic/general sepsis to become potentially life threatening condition. Methods To improve its clinical management, excisional surgery was performed on 22 patients for their 33 limbs in the end stage of lymphedema as a supplemental therapy, and its efficacy was retrospectively analyzed. Diagnosis was made by radionuclide lymphoscintigraphy and basic laboratory studies (e.g. ultrasonography, magnetic resonance imaging). Twenty-two patients (mean age: 46 years; 3 male and 19 female; 5 primary and 17 secondary) submitted to the excisional surgery on 33 limbs (unilateral: 11; bilateral: 22). Surgery was indicated by further progression of the disease with recurrent sepsis despite adequate antibiotics therapy. A modified Auchincloss-Homan's operation was used to excise grotesquely disfigured soft tissue with advanced dermato-lipo-fibrosclerotic change. The normal limb contour was re-established to allow proper postoperative therapy. Postoperative CDT and compression therapy were mandatorily implemented in all cases. Results A postoperative assessment of the treatment results, at 12 months showed an overall improvement in 28 of the 33 limbs: substantial improvement on the condition of limb function and quality of life (QOL), and local and/or systemic sepsis. Eighteen patients with good compliance to maintain the postoperative CDT showed much improved clinical results and QOL through the first interim assessment (24 months). Conclusion Excisional surgery at the end stage of lymphedema seems to provide substantial improvement of clinical condition and QOL only when mandated postoperative CDT/compression therapy is well kept.

ApoB/ApoA1 ratio and subclinical atherosclerosis.

Abstract: AIM: It has been demonstrated that an increased apolipoprotein B (ApoB)/apolipoprotein A-I (ApoA1) ratio is associated with atherogenic low density lipoprotein (LDL) particles and the development of clinical cardiovascular disease. The aim of this study was to test the hypothesis that ApoB/ApoA1 ratio is associated with early subclinical atherosclerosis as demonstrated by ultrasonic measurements. METHODS: Both common carotid and common femoral bifurcations have been scanned with high-resolution ultrasound in 767 volunteers over the age of 40. The latter consisted of 95% of the population of two randomly selected areas. IMTcc, IMTmax (including plaques), total plaque thickness (TPT) (the sum of the thickest plaques present at each bifurcation in cm) and black plaque burden (BPB) (TPT means plaque type) using the Widder classification with type 1 being the most hyperechoic and calcified and type 5 the most hypoechoic plaque were recorded. A medical history was taken with emphasis on risk factors present and a fasting lipid profile including ApoB and ApoA1 was determined. RESULTS: In the total population (N.=767) the mean (+/-SD) ApoB/ApoA1 ratio was 0.85 (+/-0.22). In linear regression analysis, the Apob/ApoA1 ratio was significantly associated with all the ultrasonic measurements of early atherosclerosis (intima media thickness, IMTcc, IMTmax, TPT and BPB). These findings remained significant after correcting for age, gender, smoking, hypertension and diabetes (P<0.001 for all). CONCLUSION: The results indicate that a high ApoB/ApoA1 ratio is associated not only with early atherosclerosis but also with hypoechoic (BPB) and by inference unstable plaques.

Autologous intra-arterial infusion of bone marrow mononuclear cells in patients with critical leg ischemia.

Abstract: Aim The injection of bone marrow mononuclear cells (BMMC) into the gastrocnemius muscle has given promising results in patients with critical limb ischemia (CLI) In this article, we have assessed whether a less invasive procedure, ie intravascular BMMC infusion, could be effective in this population of patients Methods A total of 28 limbs in 24 patients with CLI were treated An amount of 276-700 mL of marrow blood was harvested from posterior iliac crests and BMMC were obtained by standard procedure used for bone marrow transplantation After performance of digital subtraction angiography, BMMC were injected laterally through a 4 Fr sheet Primary outcome was efficacy of the procedure measured as healing of defects, frequency of high amputations and change of ischemia grade; among secondary outcomes were safety of the procedure, angiographic changes and changes in quality of life Results One year after treatment, all patients were alive and only 2 patients have undergone high amputation Eleven of 14 defects have healed (78%) and Fontaine grade of ischemia has changed from median grade 35 to median grade 2 (P<00001) Collateral vessel development has improved by mean 113 and 13 points on a four-point semiquantitative scale in calf and foot, respectively (P<00001) There were no grade Ill-TV adverse events According to the SF-36 quality of life questionnaire, 1 year after the procedure patients have reported significant improvement in all measured items Conclusion Intra-arterial infusion of BMMC can lead to significant and long-lasting subjective and objective improvements in patients with CLI The results merit validation by randomized controlled studies in patients with less critical limb ischemia

Different flavonoids present in the micronized purified flavonoid fraction (Daflon 500 mg) contribute to its anti-hyperpermeability effect in the hamster cheek pouch microcirculation.

Abstract: Aim This study evaluated microcirculatory effects of the flavonoid substances that constitute the micronized purified flavonoid fraction (MPFF) (Daflon 500 mg) in comparison to diosmin. Methods and results In groups of 3 male hamsters, oral treatment with MPFF or diosmin (15 min before anesthesia) did not alter blood pressure. At 10 or 30 mg/kg, both MPFF and diosmin significantly decreased the leaky sites caused by ischemia/reperfusion (I/R) (30 min) in the hamster cheek pouch; the effect was significantly higher with MPFF (39+/-1% and 52+/-1%, respectively) than diosmin (18+/-1% and 37+/-3%, respectively). Eight groups of 3 hamsters each were treated with the components of MPFF. Diosmetin only decreased the number leaky sites at 30 mg/kg (decrease: 15+/-2%). The decrement at 10 and 30 mg/kg averaged at: 17+/-3% and 44+/-1%, respectively, for hesperidin; 19+/-1% and 46+/-2%, respectively, for linarin; and 30+/-1% and 44+/-1%, respectively, for isorhoifolin. Hesperidin, linarin, and isorhoifolin each displayed an anti-leakage effect comparable to or greater than diosmin. MPFF decreases permeability more than any of its single constituents, suggesting that the flavonoids present in its formulation have a synergistic action. Conclusion These results illustrate that MPFF is more potent than single diosmin in this model of hyperpermeability and that each of the flavonoid substances present in MPFF contribute to its action.

Percutaneous bronchial artery embolization in the management of massive hemoptysis in chronic lung diseases. Immediate and long-term outcomes.

Abstract: Aim Bronchial artery embolization (BAE) is a well-established, non-surgical procedure in the emergency treatment of massive hemoptysis. This study aims to evaluate the immediate and long-term prognosis of BAE for the management of massive hemoptysis in our center. Methods Twenty consecutive patients (mean age: 59+/-14 years) with massive hemoptysis, underwent BAE with microspheres (Embospheres BioSphere Medical SA, Paris, France), polyvinyl alcohol particles (PVA, Ivalon, Cathmed Science; Paris, France) or/and steel coils (Cook, Denmark) after thoracic aortography and diagnostic selective and superselective catheterization of bronchial arteries and systemic collateral vessels in the bleeding lung area. Hemoptysis was due to bronchiectasis (55%), non-operable aspergillomas (15%), active tuberculosis (15%), malignancy (10%) and cystic fibrosis (5%). Mean duration of follow-up was 29+/-18 months. The recurrent-free time was calculated with Kaplan-Meier analysis. Results Immediate control of bleeding was achieved in all patients. Recurrent cases of hemoptysis were observed in 6/20 patients (30%) within 3 years and 4 of them (66.6%) occurred early in the first 3 months. Recurrent-free time was 9 months (standard error: 4) (95% confidence interval: 0-17). Repeated interventions were required in all early recurrences, due to either recanalization of the occluded arteries or non-bronchial systemic artery supply. Combined use of PVA and coils was proved effective in these cases. No serious complications were observed. Conclusion BAE is an effective and safe intervention in cases of massive hemoptysis. However, recurrences are common and long-term follow-up is considered important with a view to perform repeated interventions with combination of embolic materials.

Mid-term results following endovenous laser ablation (EVLA) of saphenous veins with a 980 nm diode laser.

Abstract: Aim To assess the mid-term results after endovenous laser ablation (EVLA) of saphenous veins by a standardized duplex and clinical protocol. Methods A non-randomized prospective trial was performed. We included a total of 67 unselected legs of 65 patients with incompetent great or small saphenous veins (GSV and SSV), confirmed by duplex ultrasound. EVLA was carried out with a 980 nm diode laser in pulsed mode and using tumescent local anaesthesia. All patients were given heparin prophylaxis and compression therapy. Patients underwent standard clinical and duplex follow-up examinations with an average of 2.2 years (0.5-3.5 years) after EVLA. Results Reflux was eliminated in 59 (88.1%) of the 67 treated veins after 2.2 (SD 0.9) years with an average energy density of 48 J/cm vein (19.8-96.1, SD 13.2). 11.9% of the cases demonstrated antegrade flow without reflux. In 8 of 67 treated legs (11.9%) reflux >0.5 s was still present. In these patients the initial vein diameter was significantly (P=0.01) higher than in the successfully treated limbs. Without reflux, the majority of treated veins, 41 of 59 (69.5%), were no longer detectable by ultrasound. In all groups with still visible veins, there was a diameter reduction of about 50%. Clinical classification (CEAP) and pitting edema similarly improved in all groups, and patient satisfaction was very high across the board. Recurrent varicose veins were significantly more frequent in the reflux group. Severe complications such as deep vein thrombosis or pulmonary embolism did not occur in any of the 67 treated cases. Conclusions EVLA of the GSV and SSV is a minimally invasive, safe and efficient treatment option with a high mid-term success rate. Not only standardized duplex, but also clinical criteria should be used in assessing the results.

Venous reflux surgery promotes venous leg ulcer healing despite reduced ankle brachial pressure index.

Abstract: AIM The aim of this study was to demonstrate that venous surgery promotes ulcer healing, even in the presence of peripheral arterial disease. METHODS In this retrospective study, 33 patients (49 legs) with venous leg ulcers and reduced arterial ankle brachial pressure index (< or = 0.8) were followed up 3 months to 7 years (median: 3.11 years) after venous surgery (group I). Venous reflux was considered to be the main cause of ulceration, and no attempt was made to restore the arterial circulation. The results were compared with those of patients with ulcers without arterial occlusive disease (n=190) who were treated following the same principles (group II). The surgical procedure consisted of interruption of reflux in the superficial and/or perforating veins. Additionally, shaving, fasciectomy, and mesh grafting was performed in 36 cases. RESULTS In group I, 21 legs were lost to follow-up, 16 due to death. The mortality rate was three times higher in group I than in group II. From 28 legs of group I seen after 0.4-6.7 years (median: 2.9 years), 19/28 legs (68%) were healed compared with 123/145 (85%) in group II after 0.2-7.2 years (median: 3.2 years) (not significant [NS]). Group I showed a significantly longer healing time than group II (P<0.05) (P<0.001). Recurrence was observed in 3/28 (11%) from group I and in 6/145 (4%) from group II (NS). The time course of recurrence showed no statistically significant difference between the groups. CONCLUSION Venous surgery produces beneficial results not only in pure venous ulcerations, but also in patients with accompanying arterial disease.

Do Italian vascular centers look for isolated calf deep vein thrombosis? Analysis of isolated calf deep vein thromboses included in the ''Master'' Registry.

Abstract: Aim. Two diagnostic imaging strategies for suspected deep venous thrombosis (DVT) in symptomatic patients are currently used: a serial compression ultrasound examination of proximal veins, or a single complete ultrasound investigation of proximal and distal veins. These strategies lead to different results since only the latter allows diagnosis of isolated calf DVT (ICDVT). Methods. We analyzed the approach of Italian centers in looking for ICDVT using the observational MASTER registry which prospectively collected information on patients with acute symptomatic venous thromboembolism. Results. ICDVT was diagnosed in 170 of the 1772 patients with leg DVT (9.6%). The rate of diagnosed ICDVT vs total DVT differed between centers from 0% to 24%. Patients with ICDVT were younger (P<0.0001); diagnosis was more frequently delayed (P<0.0001), temporary risk factors were more frequent, cancer was less frequent (P<0.001), and pulmonary embolism (PE) was more frequent at presentation (P<0.05). More ICDVT patients received LMWH only, not followed by oral anticoagulation (P<0.001). Conclusion. The diagnostic strategy for suspected leg DVT differs greatly among Italian centers. A relatively high rate of PE was recorded in patients with ICDVT for reasons which are open to debate. Prospective, well designed studies on the clinical risks and the need for diagnosing ICDVT, and the advantages/disadvantages of the two diagnostic procedures are urgently needed.

Changing trends in anti-coagulant therapies. Are heparins and oral anti-coagulants challenged?

Abstract: The conventional management of thrombotic and cardiovascular disorders is based on the use of heparin, oral anticoagulants and aspirin. Despite progress in the sciences, these drugs still remain a challenge and mystery. The development of low molecular weight heparins (LMWHS) and the synthesis of heparinomimetics represent a refined use of heparin. Additional drugs will continue to develop. However, none of these drugs will ever match the polypharmacology of heparin. Aspirin still remains the leading drug in the management of thrombotic and cardiovascular disorders. The newer antiplatelet drugs such as adenosine diphosphate receptor inhibitors, GPIIb/IIIa inhibitors and other specific inhibitors have limited effects and have been tested in patients who have already been treated with aspirin. Warfarin provides a convenient and affordable approach in the long-term outpatient management of thrombotic disorders. The optimized use of these drugs still remains the approach of choice to manage thrombotic disorders. The new anticoagulant targets, such as tissue factor, individual clotting factors, recombinant forms of serpins (antithrombin, heparin co-factor II and tissue factor pathway inhibitors), recombinant activated protein C, thrombomodulin and site specific serine proteases inhibitors complexes have also been developed. There is a major thrust on the development of orally bioavailable anti-Xa and IIa agents, which are slated to replace oral anticoagulants. Both the anti-factor Xa and anti-IIa agents have been developed for oral use and have provided impressive clinical results. However, safety concerns related to liver enzyme elevations and thrombosis rebound have been reported with their use. For these reasons, the US Food and Drug Administration did not approve the orally active antithrombin agent Ximelagatran for several indications. The synthetic pentasaccharide (Fondaparinux) has undergone clinical development. Unexpectedly, Fondaparinux also produced major bleeding problems at minimal dosages. Fondaparinux represents only one of the multiple pharmacologic effects of heparins. Thus, its therapeutic index will be proportionately narrower. The newer antiplatelet drugs have added a new dimension in the management of thrombotic disorders. The favorable clinical outcomes with aspirin and clopidogrel have validated COX-1 and P2Y12 receptors as targets for new drug development. Prasugrel, a novel thienopyridine, Cangrelor and AZD 6140 represent newer P2Y12 antagonists. Cangrelor and AZD 6140 are direct inhibitors, whereas Prasugrel requires metabolic activation. While clinically effective, recent results have prompted a closure of a clinical trial with Prasugrel due to bleeding. The newer anticoagulant and antiplatelet drugs are attractive, however, none of these are expected to replace the conventional drugs in polytherapeutic approaches. Heparins, warfarin and aspirin will continue to play a major role in the management of thrombotic and cardiovascular disorders for years to come.

The role of trans fatty acids in atherosclerosis, cardiovascular disease and infant development.

Abstract: The process of partial hydrogenation converts vegetable oils in semisolid fats, like margarines, that contain high concentrations of trans fatty acids (TFA) and are commonly used in bakery, as well as for deep frying in fast food chains and other restaurants. Initially, these fats were considered the healthy solution, because they substituted butter and other cholesterol fats. However, in the last decades there has been continuing accumulation of evidence that TFA have potential harmful action in blood lipid metabolism, atherosclerosis development and cardiovascular disease, as well as in infant development. Consequently, many countries have enacted in order to reduce total TFA percentage in the daily fat intake, while others are waiting strongest evidence to enact. This article reviews the evidence of the effects of TFA, in relation to atherosclerosis, cardiovascular disease, inflammation and diabetes, and infant development.

Men with atherosclerotic stenosis of the carotid artery have lower testosterone levels compared with controls.

Abstract: AIM There is evidence to suggest an inverse association between serum levels of testosterone and coronary heart disease. The aim of this study was to compare endogenous sex hormone levels of men with severe internal carotid artery (ICA) atherosclerosis with age-matched controls. METHODS Metabolic parameters and sex hormones were measured or calculated in 124 male patients undergoing carotid endarterectomy for high grade ICA stenosis and in 124 age-matched male controls. The presence or absence of atherosclerotic stenosis of ICA was determined by high resolution B-mode ultrasound. RESULTS The cases had statistically significant lower levels of total testosterone (TT) (medians: 3.8 microg/L versus 4.3 microg/L, P=0.005) and sex hormone binding globulin (SHBG) (means: 39.8+/-17.2 versus 54.3+/-34.3 nmol/L, P<0.001) compared to controls. Multivariate linear regression analysis, adjusted for all clinical and physiologic parameters, showed a significant inverse association between ICA stenosis and TT (b=-0.158, P=0.013) and SHBG (beta=-0.259, P<0.001). CONCLUSION This study provides evidence of a positive association between low serum androgen levels and severe ICA atherosclerosis in men. It suggests that higher, but physiological, levels of androgens could have a protective role in the development of atherosclerosis.

Effects of pentoxifylline and n-acetylcysteine on injuries caused by ischemia and reperfusion of splanchnic organs in rats

Abstract: Department of Veterinary Surgery and Anesthesiology School of Veterinary and Animal Science Universidade Estadual Paulista, Sao Paulo

Writing a case report: polishing a gem?

Abstract: Case reports describe patient cases which are of particular interest due to their novelty and their potential message for clinical practice. While there are several types of case reports, originality and clinical implications constitute the main virtues by which case reports are judged. Defining the educational message and choosing the right audience are vital steps in the process of writing. Generally, a case report is structured, its main components being the abstract, the introduction, the case description and the discussion. Guidelines and tips for writing case reports are not enough for making a successful author, but they help, especially less experienced doctors, to exercise and improve their writing. If properly prepared, case reports can still communicate new observations in an interesting and pleasant way, thereby enriching our knowledge, even in the era of evidence-based medicine.

Tissue factor, tissue pathway factor inhibitor and risk factors of atherosclerosis in patients with chronic limbs ischemia : preliminary study

Abstract: AIM Thrombus formation plays a critical role in pathogenesis of cardiovascular complications in atherosclerotic peripheral arterial occlusive disease (PAOD). Tissue factor (TF) initiates the clotting cascade and is considered an important regulator of hemostasis and thrombosis. TF activity is regulated by TF pathway inhibitor (TFPI). The aim of our study was to evaluate plasma levels of the TF, TFPI and their relation to coagulation system and various other risk factors of atherosclerosis in patients with chronic limbs ischemia. METHODS Plasma TF, total TFPI, truncated TFPI, full-length TFPI were assessed by ELISA using commercially available kits (IMUBIND Tissue Factor; Total TFPI; Truncated TFPI ELISA Kit; American Diagnostica Inc. Stamford) in 62 claudicant patients with PAOD and 20 healthy controls. RESULTS We observed statistically higher levels of TF (94+/-52 pg/mL), total TFPI (43+/-8 ng/mL), and truncated TFPI (22+/-7 ng/mL) in patients with PAOD compared to healthy individuals (TF: 66+/-15 pg/mL; total TFPI: 36+/-4 ng/mL; truncated TFPI: 14+/-5 ng/mL). Full-length TFPI (20+/-4 ng/mL) is lower in patients with PAOD than in controls (23+/-5 ng/mL). The study indicated a positive correlation between TF and truncated TFPI (r=0.34), total TFPI and full TFPI (r=0.5), total TFPI and truncated TFPI (r=0.83) in patients with PAOD, and negative correlation between full TFPI and truncated TFPI (r=-0.65) in the control. CONCLUSION Elevated levels of TF, disorders of balance between full-length TFPI and truncated TFPI as well as significantly increased truncated TFPI level in patients with PAOD can be independent risk factors of atherosclerotic complications.

Cost benefit of intermittent pneumatic compression for venous thromboembolism prophylaxis in general surgery.

Abstract: Aim. In moderate to high-risk general surgical patients, the cost effectiveness of mechanical prophylaxis for venous thromboembolism (VTE) is uncertain. Therefore, we determined the costs and savings of intermittent pneumatic compression (IPC) plus graduated compression stockings (GCS). Methods. Postoperative VTE events in the absence of prophylaxis, efficacy of prophylaxis and costs of prophylaxis have been obtained from the English literature and Medicare 2004 reimbursement schedule. Results. In 1000 moderate to high risk general surgical patients, in the absence of prophylaxis, the cost of investigating and treating 72 patients with clinical suspicion of DVT and 32 with PE is calculated to be $ 263 779. This corresponds to a cost of $ 263 per surgical patient. The cost of IPC combined with TED stockings in 1 000 similar patients would be $ 66 760, and the cost of diagnosis and treatment of the reduced numbers (69% reduction) of clinical VTE is $ 83 574 making a total of $ 150 344. This means a saving of $ 133 435 ($ 263 779-$150 344) per 1 000 patients. This corresponds to a saving of $ 113 per surgical patient. Sensitivity analysis demonstrates that despite variation in costs or efficacy for IPC plus GCS, marked savings persist. Conclusion. Prophylaxis with IPC not only prevents VTE but also saves money.

Consensus document on intermittent claudication from the Central European Vascular Forum 1st edition - Abano Terme (Italy) - May 2005 2nd revision - Portroz (Slovenia) September 2007.

Abstract: Faculty 2005: C. ALLEGRA (Rome, Italy); G. M. ANDREOZZI (Padua, Italy); P. L. ANTIGNANI (Rome, Italy); E. AROSIO (Verona, Italy); G. BREVETTI (Naples, Italy); M. COSPITE (Palermo, Italy); R. DEL GUERCIO (Naples, Italy); G. P. DERIU (Padua, Italy); C. DZSINICH (Budapest, Hungary); E. HUSSEIN (Cairo, Egypt); J. FERNANDES E FERNANDES (Lisboa, Portugal); S. FORCONI (Siena, Italy); R. MARTINI (Padua, Italy); S. NOVO (Palermo, Italy); A. PAGNAN (Padua, Italy); P. POREDOS (Ljubljana, Slovenia); H. RIEGER (Engelskirken, Germany); K. ROZTOCIL (Praha, Czech Republic); T. SOSA (Zagreb, Croatia); F. VERLATO (Padua, Italy); A. VISONÀ (Castelfranco V., Italy); P. ZAMBONI (Ferrara, Italy). Faculty 2007: G. M. ANDREOZZI (Padua, Italy); P. L. ANTIGNANI (Rome, Italy); E. AROSIO (Verona, Italy); R. CAPPELLI (Siena, Italy); S. COCCHERI (Bologna, Italy); C. DZSINICH (Budapest, Hungary); S. FORCONI (Siena, Italy); E. HUSSEIN (Cairo, Egypt); A. JECU (Timisoara, Romania); R. MARTINI (Padua, Italy); E. MINAR (Wien, Austria); A. W. NICOLAIDES (Nicosia, Cyprus); S. NOVO (Palermo, Italy); A. PAGNAN (Padua, Italy); P. POREDOS (Ljubljana, Slovenia); M. PRIOR (Verona, Italy); V. PUCHMAYER (Prague, Czech Republic); K. ROZTOCIL (Praha, Czech Republic); V. STVRTINOVA (Bratislava, Slovakia); M. SZOSTEK (Warsaw, Poland); F. VERLATO (Padua, Italy); A. VISONÀ (Castelfranco V., Italy). Writing Committee: G. M. Andreozzi, E. Arosio, R. Martini, F. Verlato, A. Visonà.

Major joint replacement. A model for antithrombotic drug development: from proof-of-concept to clinical use.

Abstract: Aim. Development of antithrombotic compounds has traditionally been performed in patients undergoing total hip and knee replacement surgery. A high number of asymptomatic deep-vein thromboses are radiologically detectable, and bleeding and other adverse events (AE) are easy to observe. However, standardization of study procedures and endpoints in early proof-of-concept studies and late pure clinical endpoint studies has been lacking. This has made comparison between studies difficult, economic analyses speculative and potential benefits of applying the drug regimen in non-selected patients uncertain. In this paper, the International Surgical Thrombosis Forum proposes a strategy for the clinical investigation of new pharmacological agents for the prophylaxis of postoperative thrombotic events. Methods. First, dose titration safety studies of short duration, in highly selected patients using objective venographic endpoints are recommended. Bleeding should be divided into the quantified volume of surgical bleeding and other adjudicated clinical bleeding events. The number of AE should be described for each dose step and classified according to International Coding of Diagnoses (ICD). Second, a dose confirmatory study of moderate exposure period and sufficient follow-up time is recommended. The exclusion criteria should be restricted to contraindications of the compaired drugs and technical procedure. Results. The efficacy, bleeding and AE should be similar to those used in dose-titration studies. In addition, the failure rate of the drug to exert its effect and the net clinical benefit should be calculated. Conclusion. Finally, trials with simple clinical endpoints and long follow-up should be conducted to evaluate the potential benefits of the drug-regimen in non-selected populations. [Int Angiol 2008;27:60-7]

Early mobilisation in patients with acute deep vein thrombosis does not increase the risk of a symptomatic pulmonary embolism.

Abstract: Aim The purpose of the study was to determine if early mobilisation in patients with acute lower limb deep vein thrombosis (DVT) increases the incidence of symptomatic pulmonary embolism (PE) and to evaluate the predisposing factors for PE such as location of the thrombus and duration of symptoms. Methods The current study was a prospective randomised clinical trial. Between January 2005 and December 2007, 219 patients with acute lower limb DVT were enrolled in the study (118 males and 101 females); the mean age was 64.2 years. Inclusion criteria 1 year, no life-threatening clinical conditions, and signed informed consent. The patients were randomised into two groups. Group A, 105 patients (47.9%) were hospitalized and received 5 days of bed rest; Group B, 114 patients (52.1%) received care at home with early walking and compression stockings. The primary end point was the presence of symptomatic PE during the first 10 days of treatment. The relationships between the duration of symptoms, location of the thrombus, and symptomatic PE were also analysed. Results Five cases of symptomatic PE were detected (2.3%), three in Group B and two in Group A. There was no significant difference in the occurrence of new PE between the two groups (P=0.54). Likewise, no difference was detected based on the duration of symptoms (P=0.62) and the location of the thrombus (P=0.43). Conclusions In acute DVT , early walking, thrombus location, and duration of the symptoms did not influence the incidence of symptomatic PE.

Compression bandages: influence of techniques of use on their clinical efficiency and tolerance.

Abstract: Aim. A bandage is characterized by its components and by its properties evaluated in vitro: stretch theoretical pressures calculated with a dynamometer. A bandage is also characterized by properties evaluated in vivo: interface pressures at rest and during contraction. The aims of this study were to evaluate interface pressures and stiffness of medium stretch bandages and to vary the techniques of bandage in order to obtain a bandage with the lowest possible resting pressure and the highest possible working pressure. Methods. The interface pressures of Biflex 16 bandages of 7 mx8 cm and of Biflex 17 of 5 mx8 cm were measured with the Kikuhime device. Five techniques to make a bandage were used: two with an overlap of 50% and 75% respectively and a stretch of 30%, two with a superimposition of 2 bandages used in the same conditions as above, and one in spica (in turns of 8-technique). Results. The achieved pressures are related to the technique of making a bandage and the number of layers at the measurement points. The best result is obtained with the Biflex 16 with an use in spica without stretch: the resting pressure is low and the working pressure is high. The stiffness index and the low resting pressure are sufficient to give a good clinical efficacy. Conclusion. This technique of use should be appropriate for the treatment of trophic disorders with a satisfactory effect of auto-massage and a maximum of safety even in a patient confined to bed or with a decreased ankle-brachial index (between 0.6 and 0.9).

Day-case angioplasty in diabetic patients with critical ischemia.

Abstract: Aim. Recent studies have shown that percutaneous transluminal angioplasty (PTA) can be safely performed as a day-case procedure. Many centers consider diabetes mellitus as a contraindication to day-case PTA. In this study, the safety and efficacy of 95 day-case PTA in 66 diabetic patients with critical leg ischemia (CLI) were evaluated. Methods. Diabetic patients with CLI were assessed in a one-stop multidisciplinary outpatient clinic. Sixty-six outpatients with CLI deemed suitable for radiological intervention by non-invasive imaging (ultrasound angiology or magnetic resonance angiography) were scheduled for day-case PTA. Results. PTA was initially successful in 63 out of 66 patients (95%). In 3 patients (5%), PTA was not possible because the lesion could not be balloon dilated or crossed with a guide wire. Clinically suspected first, second and third re-stenosis confirmed by non-invasive studies occurred in 20 out of 63 (31%), 7 out of 20 (35%) and 2 out of 7 (28%) patients, respectively. Following PTA, debridement was performed in 11 patients (17%), minor amputation in 8 (13%) and major amputation in 3 (5%). Relief of the primary symptom of rest pain or healing of ulcers was achieved in 23 out of 32 (72%) and 25 out of 27 (92.5%) patients, respectively. No peri-interventional morbidity or mortality was encountered. Conclusion. PTA is feasible and safe as a day-case procedure in diabetic patients with CLI. Re-stenosis can be managed by repeat day-case PTA.

Improvement in systemic endothelial condition following amputation in patients with critical limb ischemia

Abstract: Aim. Most patients with critical limb ischemia (CLI) have co-existing coronary heart disease, which is the main cause of their increased mortality. Peripheral ischemic tissue produces circulating toxic molecules, which may worsen endothelial function systemically and contribute to the general atherosclerotic process within the body. We looked at whether markers of endothelial function improve after amputation of the ischemic limb, when this potential source of toxins has been removed. Methods. We measured blood levels of vascular endothelial growth factor (VEGF), homocysteine, endothelin-1, vascular cell adhesion molecule-1, E-selectin, thrombomodulin and von Willebrand factor (vWF) in 40 patients with CLI. We also assessed peripheral microvascular function in forearm skin by measuring responses to iontophoresis of acetylcholine and sodium nitroprusside. The measurements were repeated 6 months after amputation. Results. We found abnormally high levels of endothelial products in the patients, and 6 months later VEGF and vWF had both reduced significantly from previous values (by 70% and 40%, respectively; P<0.01 in both cases). Conclusion. Improvements in these two markers after amputation are consistent with the hypothesis that peripheral ischemic tissue has a systemic effect on the vascular endothelium and may contribute to the progression of coronary heart disease in patients with CLI.

Effectiveness and costs of a short-course supervised training program in claudicants: proposal for a shared protocol with aerobic working load.

Abstract: AIM The purpose of this study was to assess the costs and effectiveness of a short-course physical training program, consisting of an aerobic protocol with clearly defined working loads in each single training session, in patients with intermittent claudication (IC). METHODS Initial (ICD), absolute (ACD) claudication distance, and recovery time (RT) have been measured by maximal treadmill exercise in 74 claudicants. Ankle brachial index (ABI) has been measured too. Measurements have been repeated after 18 days of supervised physical training consisting of a daily walk reaching either a distance goal of 1-2 km or a time goal of at least 30 min. The working load of each single training session has been tailored at 60-70% of the ACD measured by a non-maximal treadmill exercise. RESULTS ICD increased from 56.2 (+/- standard deviation/+/- standard error: 35.3/4.1) to 123.9 (66.5/7.7); ACD increased from 104.8 (49.8/5.8) to 195.1 (81.7/9.5) and RT reduced from 201.2 (98.3/11.4) to 85.8 (43.6/5.1), with P<0.0001 for all parameters. We analyzed separately patients with moderate (M-CL) and severe (S-CL) claudication, and found significant improvements in both groups. The Ds (post-training value minus pretraining value) were: ICD 89.6 (59.9/10.9) in M-CL and 50.2 (29.9/4.6) in S-CL; ACD 102.8 (66.8/11.6) in M-CL and 80.1 (41.5/6.4) in S-CL; RT -98.7 (86.9/15.1) in M-CL and -128.5 (88.1/13.7) in S-CL, with P<0.0001 for all parameters. The differences between M-CL and S-CL were significant only for ICD (P=0.0003) and ACD (P<0.05). ABI showed an increasing trend, which was statistically significant (P<0.001), but clinically irrelevant. The protocol cost was 4179 Euro (average cost 46.30 Euro to walk one additional meter). CONCLUSION Supervised physical training is confirmed to be an effective tool for the treatment of IC, and the proposed short-course protocol gave the same improvements as the longer ones while reducing the costs. The proposed procedure for tailoring the working load of a single session identifies clearly the working load, near maximal pain but avoiding the risk of inflammatory activation.

Risk factors, atrial fibrillation and thromboembolic events.

Abstract: Aim. The aim of this study was to evaluate the relation between risk factors for atrial fibrillation (AF) and thromboembolic complications. Methods. We studied 480 patients (mean age: 71.2±11.6 years): 240 with paroxysmal AF, 240 with permanent AF. The association between AF and the presence of risk factors, cardiac and systemic disease was observed and the correlation with the occurrence of complications analyzed. Results. Patients with AF had a high prevalence of the following conditions: hypertension, hypertensive heart disease (HHD), coronary artery disease, hyperthyroidism. Thromboembolism was observed in 26.6% of the patients. A correlation between the occurrence of a thromboembolic complication and the presence of one of the following risk factors for thromboembolism was observed: older age, diabetes mellitus, HHD and hyperfibrinogenemia. No correlation was detected between: female sex, arterial hypertension, hypercholesterolemia, smoking, and obesity. Exitus was observed in 7 patients with permanent AF. Conclusion. Older age, diabetes mellitus, HHD and hyperfibrinogenemia were strongly associated with the occurrence of thromboembolic complications. Patients with effectively pharmacologically controlled hypertension had not more frequently thromboembolic complications. A strict blood pressure control may prevent thromboembolic complications of AF.

The role of duplex ultrasonography in the diagnosis of lower-extremity deep vein thrombosis in non-hospitalized patients.

Abstract: Aim. The aim of this study is to reassess the diagnostic evaluation using duplex scanning in non-hospitalized patients, suspected of having deep vein thrombosis (DVT) of the lower limbs. Methods. In a period of 4 years, 589 patients suspected of having DVT of the lower limbs were submitted to duplex scanning for diagnostic confirmation. The patient complaints were pain, edema or color alteration of the extremity, associated with a risk factor or not. The time span between the beginning of symptoms and the ultrasound was considered as well, with the examination being conducted only on the member that presented the signs or symptoms, or on both in case of suspicion of pulmonary embolism. This study features 203 male patients and 386 female patients, aged 19 to 93. Results. In Group I, of the 139 patients who displayed acute venous thrombosis (N=77), 55.4% had at least one associated risk factor; in Group II, of the 96 patients with chronic thrombosis (N=72), 75% had an associated risk factor that predominated the previous history of illness; and in Group III, in 354 patients without DVT, 161 of them (45.5%) featured some associated risk factor. Conclusion. It was concluded that duplex scanning is a useful tool for offering a prompt and efficient diagnosis of venous thrombosis as well as displaying alterations in adjacent structures, thus facilitating the differential diagnostic with other conditions, although in many patients (32.7%) the examination was done unnecessarily, with irrelevant clinical signs and in the absence of any evident risk factor. [Int Angiol 2008;27:377-84]

Overview of extremity arterial trauma in Jordan.

Abstract: Aim. The objectives of this study were to review etiologies of trauma, associated injuries, diagnosis, management, and outcomes of patients with vascular injuries in the extremities and relate factors in their treatment to the outcome of the injured extremity. Methods. Data were collected retrospectively on 73 patients diagnosed to have upper and lower limbs arterial injuries at King Abdullah University Hospital, Jordan, between 2001 and 2006. Factors evaluated included demographic data, location of vessels injured, mechanism of injury, associated injuries, treatment, and outcome. Results. Patients were predominantly males (54 patients). Isolated vascular trauma was present in 36 patients, while in the remaining 37 patients vascular trauma was aggravated by concomitant injuries. The most common etiology of vascular injuries in the upper and lower extremities was a penetrating injury found in 38 patients (52%). The vessels most commonly involved were the femoral and brachial arteries. Various associated injuries were identified mainly orthopedic in 21 patients (29%) and nerve injuries in 18 patients (25%). Autogenous vein graft interposition was mostly performed in 32 patients (44%). Permanent disability was seen in 8 patients (11%), limb amputation was performed in 5 patients (7%). Five patients died due to associated intraabdominal, thoracic, and head injuries giving a mortality rate of 7%. Conclusion. Delay in surger, blunt trauma and extensive soft tissue defect in combined orthopedic and vascular injuries were associated with increased risk of amputation, while associated nerve injuries and bone injuries with extensive soft tissue damage are risk factors of poor quality outcome.