Showing papers in "International Angiology in 2015"

IUA-ISVI consensus for diagnosis guideline of chronic lymphedema of the limbs.

Abstract: The current document is intended to define a consensus on the diagnostic guidelines for patients with lymphedema, based upon literature­based evidence, both clinical and investigative. General diagnostic guidelines include systemic evaluation; assessment of venous function; duplex ultrasonography; and lymphoscintigraphy. Proper diagnosis should allow appropriate clinical and laboratory staging of the disease for the assessment of progression of the condition and its response to treatment. Diagnosis should include an assessment of the infections in the early and latent stages. Lymphedema is assessed by the stage of disease (0­III) and WHO guidelines for International Classification of Functioning, Disability and Health and Quality of Life issues can be used as a reference for the impact of this complex condition on social, emotional, and physical function. It is the authors’ intent that this document stimulate further inquiry and discussion regarding all aspects of lymphedema diagnosis.

Society for Vascular Surgery and American Venous Forum Guidelines on the management of venous leg ulcers: the point of view of the International Union of Phlebology.

Abstract: Society for Vascular Surgery and American Venous Forum Guidelines on the management of venous leg ulcers : the point of view of the International Union of Phlebology

ISVI-IUA consensus document diagnostic guidelines of vascular anomalies: vascular malformations and hemangiomas.

Abstract: The diagnostic approach to vascular anomalies should include the distinction between vascular tumors (i.e. hemangiomas) and congential vascular malformations (CVMs). This step is based more on history and clinical examination rather than on instrumental evaluation. In children Duplex ultrasound and histology can be helpful to separate hypervasularized tumors from CVMs. Appropriate record of objective measures as size or flow volume is required in order to evaluate the progress of the pathology and/or to assess the results of adopted therapeutic interventions. The anatomic, pathological and hemodynamic characteristics, the secondary effects on the surrounding tissues and the systemic manifestations should be defined. Basic diagnostic tools are Duplex sonography followed by MRI or CT scanning. The definition of the vascular anomaly should be according to the Hamburg classification and should separate vascular tumors from vacular malformations followed by separation of high flow from low flow CVMs. Diagnostic investigations are best undertaken at centers where subsequent therapeutic interventions will be performed.

Analysis of the effects of micronized purified flavonoid fraction versus placebo on symptoms and quality of life in patients suffering from chronic venous disease: from a prospective randomized trial.

Abstract: Aim The aim was to investigate the effect of micronized purified flavonoid fraction (MPFF; Daflon® 500 mg, Laboratoires Servier, France) versus placebo, on pain and quality of life (QoL) in patients with symptomatic chronic venous disease (CVD). Methods A large randomized, double-blind, placebo-controlled, parallel-group study was conducted to evaluate treatment effects on vesperal oedema using water displacement volumetry (WDV). Other criteria were leg pain\heaviness assessed by Visual Analog Scale (VAS) and Quality Of Life Questionnaire (CIVIQ-20). Study treatments were administered once a day for 4 months. The tolerance to the study treatments was assessed based on spontaneously reported adverse events, coded using the MedDRA dictionary. The present post-hoc analysis focuses on the subgroup of symptomatic patients having a baseline VAS>4 cm. Results The main study included 1137 patients classified C3 or C4 according to CEAP classification, with 592 in the symptomatic subgroup: 296 randomized to MPFF and 296 to placebo. Patient demographics and medical history were well-balanced at baseline. The main study was inconclusive on WDV for methodological reasons. In the symptomatic subgroup, MPFF treatment was associated with a greater reduction in VAS score than on placebo treatment (between-group difference =-0.5 cm; P=0.031) and greater improvement in CIVIQ score (between-group difference =3.1%; P=0.040). Conclusion A 4-month treatment with MPFF significantly reduced leg pain/heaviness and improved QOL when compared to placebo and was well tolerated.

Endovenous laser ablation of the great saphenous vein comparing 1920-nm and 1470-nm diode laser.

Abstract: BACKGROUND The aim of this study was to compare venous occlusion rates at a one-year follow-up comparing 1920-nm versus 1470-nm endolaser. METHODS Randomized prospective study with consecutive patients with varicose veins associated to great saphenous reflux. The 1470-nm laser ablation was performed in continuous mode, with power of 10 W, while for the 1920-nm it was set in 5 W. Follow-up data were collected at the 7-day, 30-day, 3-month, 6-month and 1-year visits, and involved clinical, ultrasound evaluation and measurement of occlusion length. RESULTS Sixty seven patients were included, with 42 limbs operated in the 1470-nm group and 48 limbs in the 1920-nm group. There were no differences in relation to age, CEAP (Clinical, Etiologic, Anatomical and Pathological Classification), VCSS (Venous Clinical Severity Score) and saphenous diameter. The resulting LEED in 1920-nm group was 17.8±0.6 J/cm and vs. 24.7±0.8 J/cm in 1470-nm group (P<0.01). Closure rates were lower for the 1920-nm group: 90.9% vs. 96.8% (P=0.06) at 30 days, 87.5% vs. 96.3% at 6 months (P=0.03), and 87.5% vs. 94.7% (P=0.05) at one year. The 1920-nm group had less ecchymosis (18.7% vs. 52.4%), induration (12.4% vs. 38.1%) and days of analgesic use (1.4±0.2 vs. 2.4±0.4). CEAP and VCSS were reduced over time in both groups. CONCLUSIONS Treatment with endolaser 1920-nm was feasible and with reduced complications. The use of low endoluminal energy resulted in lower vein occlusion rates comparing to the 1470-nn laser. Clinical outcome scores were similar between groups.

Matrix metalloproteinases and peripheral arterial disease.

Abstract: It has been postulated that atherosclerosis should be considered as a chronic inflammatory process and peripheral arterial disease (PAD) is a manifestation of such an atherosclerotic vascular disease. Matrix metalloproteinases (MMPs) are significant circulating biomarkers which play a pivotal role in the initiation, progression and clinical manifestations of PAD. This review summarizes the current body of evidence with regard to the association between MMPs and PAD.

A contemporary meta-analysis of the association of diabetes with abdominal aortic aneurysm.

Abstract: AIM Aim of the present study was to determine whether diabetes is independently and inversely associated with prevalence of abdominal aortic aneurysm (AAA). We performed a meta-analysis of contemporary literature in which adjusted (but not unadjusted) relative risk estimates are available. METHODS MEDLINE and EMBASE were searched from January 1999 to April 2014 using Web-based search engines (PubMed and OVID). Studies considered for inclusion met the following criteria: the design was a prospective-cohort, population-screening, or case-control study; the study population was individuals with and without diabetes or AAA; and outcomes included adjusted (but not unadjusted) relative risks for prevalence/incidence of AAA in patients with diabetes versus subjects without diabetes. Study-specific adjusted relative risk estimate were combined using inverse variance-weighted average of logarithmic odds ratios (or hazard ratios) in the random-effects model. RESULTS Of 324 potentially relevant articles screened initially, 13 eligible studies were identified and included. A pooled analysis of all the 13 studies demonstrated that diabetes was significantly associated with lower prevalence of AAA (odds ratio, 0.59; 95% confidence interval, 0.52 to 0.67; P<0.00001). When data from 6 prospective-cohort, 5 population-screening, and 2 case-control studies were separately pooled, diabetes was also significantly associated with lower prevalence of AAA (P for subgroup differences =0.05). CONCLUSION Diabetes appears to be inversely associated with prevalence of AAA.

Surgical complications of carotid body tumors surgery: a review.

Abstract: Carotid body tumor (CBT) is a rare neoplasm, although it represents about 65% of head and neck paragangliomas Surgical excision is considered the appropriate therapy for CBTs The aim of this study was to evaluate surgical outcomes on a large scale We reviewed 19 studies between 2004 to 2014 with a total of 625 procedures We observed a higher number of cases in women (62%) Only 3 (0,48%) deaths were reported as surgical complication Total cranial nerve injuries were 302 (48,32%) of which 194 (31,04%) were transient and 108 (17,28%) were permanent We found a total of 174 (27,84%) arterial injuries, most of which are external carotid artery (ECA) injuries Cerebrovascular accident due to surgery were 15 (2,4%) We concluded that surgical resection remains the treatment of choice for these disease despite the related morbidity

Sulodexide suppresses inflammation in patients with chronic venous insufficiency.

Abstract: AIM According to previously performed studies, inflammation plays a crucial role in vein wall and leg tissue injury related to chronic venous insufficiency (CVI) development. Sulodexide (SUL) is a balanced mix of glycosaminoglycans with potential anticoagulant and profibrinolytic activity, also protecting endothelial cells and suppressing inflammatory reactions in various vascular disease-related conditions. The goal of the present study was to evaluate the anti-inflammatory action of SUL in patients with CVI. METHODS The study was performed on a group of 11 patients with chronic venous disease (stage C5 according to CEAP classification). The mean age of the patients was 58.4±7.7 years, and none of them were diabetic. The patients were treated for 8 weeks with orally-administered SUL (2 x 500 LSU/day). Blood samples were collected at the start and at the end of the study for measurement of MMP-9, IL-6 and monocyte chemoattractant protein-1 (MCP-1). Additionally, the effect of the obtained serum samples on the function of human venous endothelial cells (HVEC) in in-vitro culture was evaluated. RESULTS After treatment with SUL, the serum concentration of MMP-9 (ng/mL) decreased from 6.50±3.48 to 5.41±1.36, P<0.05, and the concentration of IL-6 (pg/mL) decreased from 11.5±3.4 to 10.1±2.3, P<0.005. There was also a trend of decreased serum MCP-1 (pg/mL) from 31.3±23.0 before treatment to 27.1±10.7 at the end. Intracellular generation of oxygen-derived free radicals in HVEC maintained in in-vitro culture was lower in the serum samples collected after treatment with SUL: 3.09±0.35 abs/μg protein vs. 3.63±0.32 abs/μg protein, at the start, P<0.05. Synthesis of IL-6 was lower in HVEC exposed in vitro to serum collected at the end of SUL treatment: 1.02±0.31 ng/μg cell protein vs. 1.32±0.41 ng/μg cell protein before SUL treatment. The proliferation rate of HVEC was similar in serum collected at the beginning and at the end of SUL treatment. CONCLUSION We conclude that treatment with SUL in patients with CVI reduces intravascular inflammation and is protective for the endothelial cells and for the extracellular matrix changes related to metalloproteinase expression.

Pycnogenol® and Centella asiatica in the management of asymptomatic atherosclerosis progression.

Abstract: AIM The aim of the study was to evaluate the effect of the nutritional supplements Pycnogenol® and total triterpenic fraction of Centella asiatica (TTFCA) on atherosclerosis progression in low-risk asymptomatic subjects with carotid or femoral stenosing plaques. METHODS This was an observational pilot, substudy of the San Valentino epidemiological cardiovascular study. The study included 824 subjects aged 45-60 without any conventional risk factors who had a stenosing atherosclerotic plaque (>50-60%) in at least one carotid or common femoral bifurcation, allocated into 6 groups: Group 1 (Controls): management was based on education, exercise, diet and lifestyle changes. This same management plan was used in all other groups; group 2: Pycnogenol® 50 mg/day; group 3: Pycnogenol® 100 mg/day; group 4: Aspirin® 100 mg/day or ticlopidine 250 mg/day if intolerant to aspirin; group 5: Aspirin® 100 mg/day and Pycnogenol® 100 mg/day; group 6: Pycnogenol® 100 mg/day plus TTFCA 100 mg/day. The follow-up lasted 42 months. Plaque progression was assessed using the ultrasonic arterial score based on the arterial wall morphology and the number of plaques that progressed and on the number of subjects that had cardiovascular events. A secondary endpoint was to evaluate the changes in oxidative stress at baseline and at 42 months. RESULTS The ultrasonic score increased significantly in groups 1, 2, and 4 (>1%) but not in groups 3, 5 and 6 (<1%) suggesting a beneficial effect of Pycnogenol® 100 mg. Considering the percent of patients that progressed from class V (asymptomatic) to VI (symptomatic) there was a progression of plaques in 48.09% of controls. In the Pycnogenol® 100 (group 3, 10.4%) and in the Aspirin®+ Pycnogenol® (group 5, 10.68%) progression was half of what observed with antiplatelet agent (group 4, 20.93%); in the TTFCA+ Pycnogenol®group (group 6) progression was 7.4 times lower than in controls; 3.22 times lower than in the antiplatelet agents group (4). Events (hospital admission, specialized care) were observed in 16.03% of controls; there were 8.83% of subjects with events with Pycnogenol® 50 mg and 8% in group 3 (Pycnogenol® 100 mg). In group 4 (antiplatelets), 8.52% of subjects had events; in group 5, 6.87% of subjects had events and in group 6 (TTFCA+ Pycnogenol®) only 4.41% had events (this was the lowest event rate; P<0.05). All treatment groups had a significantly lower event rate (P<0.05) in comparison with controls. Considering treatments groups 2, 3, 5, 6 had a lower number (P<0.05) of subjects in need of cardiovascular management in comparison with controls. The need for risk factor management was higher in controls and lower in group 6 (P<0.05). In groups 2 to 6 the need for risk factor management was lower than in controls (P<0.05). Including all events (hospital admission, need for treatment or for risk management) 51.9% of controls were involved. In the other groups there was a reduction (from a -9.28% reduction in group 2 to a -26% in group 6) (P<0.002). The most important reduction (higher that in all groups; P<0.05) was in group 6. At 42 months, oxidative stress in all the Pycnogenol® groups was less than in the control group. In the combined group of Pycnogenol® and TTFCA the oxidative stress was less than with Pycnogenol® alone (P<0.001). CONCLUSION Pycnogenol® and the combination of Pycnogenol® +TTFCA appear to reduce the progression of subclinical arterial plaques and the progression to clinical stages. The reduction in plaque and clinical progression was associated with a reduction in oxidative stress. The results justify a large, randomized, controlled study to demonstrate the efficacy of the combined Pycnogenol® and TTFCA prophylactic therapy in preclinical atherosclerosis.

Medical management of patients with peripheral arterial disease.

Abstract: Peripheral arterial disease (PAD) is one of the most frequent manifestations of atherosclerosis and is associated with atherosclerosis in the coronary and carotid arteries, leading to a highly increased incidence of cardiovascular events. Major risk factors of PAD are similar to those that lead to atherosclerosis in other vascular beds. However, there are differences in the power of individual risk factors in the different vascular territories. Cigarette smoking and diabetes mellitus represent the greatest risks of PAD. For prevention of the progression of PAD and accompanying cardiovascular events similar preventative measures are used as in coronary artery disease (CAD). However, recent data indicate that there are some differences in the efficacy of drugs used in the prevention of atherothrombotic events in PAD. Antiplatelet treatment is indicated in virtually all patients with PAD. In spite of the absence of hard evidence- based data on the long term efficacy of aspirin, it is still considered as a first line treatment and clopidogrel as an effective alternative. The new antiplatelet drugs ticagrelol and prasugrel also represent promising options for treatment of PAD. Statin therapy is indicated to achieve the target low density lipoprotein cholesterol level of ≤2.5 mmol/L (100 mg/dL) and there is emerging evidence that lower levels are more effective. Statins may also improve walking capacity. Antihypertensive treatment is indicated to achieve the goal blood pressure (<140/90 mmHg). All classes of antihypertensive drugs including beta-blockers are acceptable for treatment of hypertension in patients with PAD. Diabetic patients with PAD should reduce their glycosylated haemoglobin to ≤7%. As PAD patients represent the group with the highest risk of atherothrombotic events, these patients need the most intensive treatment and elimination of risk factors of atherosclerosis. These measures should be as comprehensive as those in patients with established coronary and cerebrovascular disease.

Outcome of open versus endovascular abdominal aortic aneurysm repair in obese patients: a systemic review and meta-analysis.

Abstract: AIM Obesity is increasingly common among patients diagnosed with vascular disease. This article aims to perform systemic review and meta-analysis on 30-day postoperative mortality and complication rate between open (OAR) and endovascular (EVAR) abdominal aortic aneurysm repair in obese patients. METHODS A systematic search was performed using the PubMed, Embase and Cochrane databases to identify original articles on obese (BMI ≥30) patients undergoing abdominal aortic aneurysm (AAA) repair. Outcomes considered were 30-day mortality and postoperative complication rate following OAR or EVAR. Random-effects Poisson regressions were fitted for each outcome to estimate the risk ratios comparing EVAR to OAR. RESULTS Four studies were included in the final analyses, all of which were observational in nature. There was no evidence of publication bias as suggested by funnel plots of the outcomes. Meta-analysis showed statistically significant fewer 30-day postoperative mortality in favour of EVAR (risk ratio 0.34 [95% confidence interval 0.25, 0.48], 4 studies, 2440 patients) and early postoperative complications: myocardial infarction (0.29 [0.13, 0.64]), chest infection (0.21 [0.12, 0.38]), renal failure (0.24 [0.11, 0.51]), wound infection (0.59 [0.48, 0.74]). Risk of postoperative bowel ischemia (0.26 [0.06, 1.13]) and stroke (0.32 [0.07, 1.55]) were equivocal between EVAR and OAR. CONCLUSION The current study strongly suggests EVAR is superior to OAR with regards to 30-day mortality and early postoperative outcome in obese patients.

Clinical experience with Angiojet: a comprehensive review.

Abstract: The development of various sophisticated mechanical thrombectomy devices and the amassed experience of physicians in minimal invasive therapy produced a paradigm shift in vascular access management toward percutaneous declotting procedures, using pharmaceutical thrombolysis, mechanical thrombectomy, balloon thrombectomy, and a combination of the above techniques. In this setting, in the last years, AngioJet™ (Possis, Minneapolis, MN, USA) rheolytic thrombectomy (RT) showed an increasing use in emergency and election patients. The purpose of this review is to present the current status of percutaneous rheolytic thrombectomy in different fields of applications.

Effects of Pycnogenol® on endothelial dysfunction in borderline hypertensive, hyperlipidemic, and hyperglycemic individuals: the borderline study.

Abstract: AIM This registry study aimed to evaluate the effects of supplementation with pycnogenol on altered endothelial function (EF) in borderline hypertensive, hyperlipidemic and hyperglycemic subjects without atherosclerotic changes in their main arteries and no coronary artery disease. METHODS Flow mediated dilatation (FMD) and endothelium-independent (EID) dilatation were measured with brachial ultrasound after occlusion. Also, after occlusion, laser Doppler (LDF) flux and distal straingauge flow were measured. Oxidative stress (oxstress) was evaluated at 8 and 12 weeks. 93 subjects with borderline symptoms were enrolled into the study: 32 hypertensives, 31 hyperlipidemics, 30 hyperglycemics. All participants were instructed to follow the best available management to control their symptoms. In addition to best management, half of the subjects in each group used 150 mg/day Pycnogenol(®). 31 normal subjects were included as control. RESULTS After 12 weeks metabolic values and blood pressure were back to normal in all subjects. Values were slightly better under Pycnogenol(®). FMD increased after 8 weeks from an average 5.3;3.4% to 8.2;2.2% with a further increase to 8.8;3.1% (P<0.05) at 12 weeks. No effects were found in controls and normal subjects. EID of normal subjects was consistently higher with 26%. LDF skin flux increased with Pycnogenol(®) at 8 weeks and 12 weeks. The final flux increase was not different from normal values. In controls flux after occlusion was not improved at 8 weeks; there was a significant but minor increase at 12 weeks. Flux increases were superior in all Pycnogenol(®) subjects. In Pycnogenol(®) subjects, limb flow after occlusion increased at 8 weeks with a further increase at 12 weeks. In controls inclusion flow after occlusion was comparable at 8 and 12 weeks. Oxidative stress was significantly decreased in Pycnogenol(®) subjects at 8 and 12 weeks. Minor differences were observed in controls. CONCLUSION This open registry study indicates that Pycnogenol(®) improves EF in preclinical, borderline subjects in a macro-microcirculatory model. This observation may suggest an important preventive possibility for borderline hypertensive, hyperglycemic and hyperlipidemic subjects.

Renovascular anatomic variants at CT angiography.

Abstract: Aim The aim of this paper was to assess the origin and course variations of vessels forming the renal vascular pedicle. Methods The IRB approved study retrospectively evaluated 921 consecutive patients (503 females, 418 males; mean age, 54 years), who underwent multidetector computed tomographic (MDCT) of the abdomen for various purposes at our Department of Radiology, between January 2012 and December 2013. Multiplanar and volumetric reformations were performed in all cases. For each set of images, the locations of renal artery origins and renal venous drainage, such as all renal vessels variations, including division variations and presence of extrarenal vessels, were investigated. Results The tract of the aorta between the upper margin of L1 and the lower margin of L2 originated 96% of main renal arteries and 72% of extra renal arteries. The most common location for renal artery origin was the L1- L2 intervertebral disc level. Sixty-nine percent of patients showed a single renal artery, with multiple arteries in 31%, bilateral multiple arteries in 11%, and early division in 6% of cases. Additional renal arteries were detected on the right side in 5% and on the left side in 12% of cases. With regard to the venous drainage, 89.8% of patients showed a single renal vein, with multiple vein in 10.2%, while 23.8% showed a retro-aortic course of the renal vein. Conclusion Renal arteries and veins variations of origin and course are not infrequent. Extrarenal vessels may compromise renal surgery. The awareness of any possible renovascular anomaly is crucial in case of a non-invasive diagnostic search for renal artery stenosis, and when renal surgery related to renal arteries is performed, such as in case of interventional radiological procedures, urological and vascular operations, and renal transplantation.

Statins and peripheral arterial disease.

Abstract: Peripheral arterial disease (PAD) in the context of this review refers to the presence of atherosclerotic disease in the arteries of the lower limbs. PAD is the third main site of atherosclerosis, after coronary heart disease and cerebrovascular disease. Intermittent claudication (IC) is the most known clinical manifestation of PAD, although most patients with leg ischemia are either asymptomatic of have atypical leg symptoms. Different drugs have been used in the past for the treatment of IC with limited results. As hypercholesterolemia is one of the main risk factors for atherosclerosis, cholesterol reduction has been shown to be effective in reducing cardiovascular morbidity and mortality. Statins are inhibitor of HMG CoA reductase, an enzyme essential in cholesterol synthesis. They effectively reduce total cholesterol and LDL cholesterol levels and are the most efficient drugs available today in the treatment of hypercholesterolemia. Several studies have demonstrated that statin administration in patients with PAD results in a decreased progression and even regression in the growth of the atherosclerotic plaque. As patients with atherosclerosis of the lower limbs have frequently concurrent coronary or cerebrovascular disease, treatment of PAD with statins results in a simultaneous decrease in the incidence of coronary events and stroke. Statins have associated pleiotropic effects, including anti-inflammatory properties that contribute to their beneficial effects and to the reduction in cardiovascular death. In addition, several studies during the last years showed that statins improved pain-free walking distance, ankle brachial index and treadmill exercise time. As a result, current guidelines for cholesterol reduction in PAD patients adhere to the same indications as for other cardiovascular diseases and strongly recommend the administration of statins in these patients.

Intima-media thickness: correlation between carotids, vertebral artery, aorta and femoral arteries.

Abstract: Aim Compare the intima-media thickness (IMT) of the internal carotid artery with the IMT of the common and external carotid, vertebral and femoral arteries and the abdominal aorta to assess the possibility of using these arteries as markers of atherosclerotic disease. Methods Fifty patients with atherosclerosic risk factors were examined and the IMT was determined in the carotid arteries and compared with the values of IMT of the vertebral and femoral arteries and the abdominal aorta. The Spearman correlation coefficient and Kappa index were used for statistical analysis. Results Considering IMT equal or greater than 0,8mm, there was positive and significant correlation between the values obtained for the examined arteries. The best agreement was found between the external and common carotid artery as compared to the internal carotid. (accuracy of 73.5% and 79.2%, respectively). For all arteries the was a positive correlation of the values of the EMI. Conclusion There is positive and significant correlation between the IMT of the internal carotid artery and the vertebral and femoral arteries and abdominal aorta. Routine examinations of either one of these arteries can ad important findings regarding early diagnosis for higher risk patients concerning atherosclerotic disease.

Vitamins and abdominal aortic aneurysm.

Abstract: Introduction To summarize the association of vitamins (B6, B12, C, D, and E) and abdominal aortic aneurysm (AAA), we reviewed clinical studies with a comprehensive literature research and meta-analytic estimates. Evidence acquisition To identify all clinical studies evaluating the association of vitamins B6/B12/C/D/E and AAA, databases including MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched through April 2015, using Web-based search engines (PubMed and OVID). For each case-control study, data regarding vitamin levels in both the AAA and control groups were used to generate standardized mean differences (SMDs) and 95% confidence intervals (CIs). Evidence synthesis Pooled analyses of the 4 case-control studies demonstrated significantly lower circulating vitamin B6 levels (SMD, -0.33; 95% CI, -0.55 to -0.11; P=0.003) but non-significantly lower vitamin B12 levels (SMD, -0.42; 95% CI, -1.09 to 0.25; P=0.22) in patients with AAA than subjects without AAA. Pooled analyses of the 2 case-control studies demonstrated significantly lower levels of circulating vitamins C (SMD, -0.71; 95% CI, -1.23 to -0.19; P=0.007) and E (SMD, -1.76; 95% CI, -2.93 to 0.60; P=0.003) in patients with AAA than subjects without AAA. Another pooled analysis of the 3 case-control studies demonstrated significantly lower circulating vitamin D (25-hydroxyvitamin D) levels (SMD, -0.25; 95% CI, -0.50 to -0.01; P=0.04) in patients with AAA than subjects without AAA. In a double-blind controlled trial, 4.0-year treatment with a high-dose folic acid and vitamin B6/B12 multivitamin in kidney transplant recipients did not reduce a rate of AAA repair despite significant reduction in homocysteine level. In another randomized, double-blind, placebo-controlled trial, 5.8-year supplementation with α-tocopherol (vitamin E) had no preventive effect on large AAA among male smokers. Conclusions In clinical setting, although low circulating vitamins B6/C/D/E (not B12) levels are associated with AAA presence, vitamins B6/B12/E supplementation may not reduce AAA incidence.

Selective high ligation of the sapheno-femoral junction decreases the neovascularization and the recurrent varicose veins in the operated groin

Abstract: Aim High ligation (HL) and stripping of GSV can be distinguished in Babcock's radical ligation (RHL), and selective (SHL): the new technique consists to ligate the SFJ keeping some of the tributary veins. The study analyzes the neovascularization and recurrence incidence in the groin after the SHL. Methods A retrospective study performed in a center specialized in venous surgery in Italy, it included 360 patients underwent unilateral varicose vein surgery from January 2001 to December 2008 (210 females and 150 males, mean aged 51.9 years, range 18 to 75 years, the limbs were 222 rights and 138 lefts), CEAP classification was C2,s. Operative technique was standardised to SFJ ligation with the SHL, the GSV was stripped to the level of the knee, multiple phlebectomies were performed and the ligation of the incontinent perforating veins was performed if it was necessary. All patients had a venous reflux from terminal valve of SFJ and the femoral valves were continent. All patients were submitted to clinical examination of the lower limbs and Duplex Scanning (DS) in the pre/postoperative period every year after surgery and by two independent operator in 2013. The follow-up is from 5 years for the patients operated in 2008 to 12 years for the patients operated in 2001. Results The neovascularizations and recurrencies in the groin were founded in 7 patients, the incidence is 1.9% of the total cases. The GSV stump and the left tributaries were open to venous flow, it was no venous reflux from the groin, no venous thrombosis of the GSV stump were detected. Conclusion The SHL of the SFJ is a reliable technique, decreasing the incidence of neovascularizations and recurrent varicose veins in the operated groin.

Endovenous laser treatment of saphenous veins: is there clinical difference using different endovenous laser wavelenghts?

Abstract: Endovenous laser treatment (EVLT) is an efficient method to treat incompetent saphenous veins with high occlusion rates. Major side effects reported with 810 nm and 980 nm diode laser are postoperative pain and bruising. Recently laser systems with higher wavelengths (WSLWs), associated with new energy delivery devices, seem to reduce some side effects previously reported. Aim of this study is to verify if there are real clinical advantages in the use of WSLWs, reviewing the comparison studies present in the literature. After a search on MEDLINE database, a review of all papers concerning WSLWs, was made. Five studies of comparison between different wavelength, 810 vs.. 980 nm, 940 vs.. 1320 nm, 810 vs.. 1320 nm, 980 vs.. 1500 nm and 980 vs.. 1470 nm were found. These studies report similar results: the WSLWs produce fewer side effects. New optical fibers have also been developed; WSLWs with the use of these new fibers dramatically changed the postoperative period, with a reduction of pain and bruising. There is no scientific evidence that WSLWs have any effect on long-term outcome, although short-term differences have been found for some side effects. Other parameters are also important: in particular, LEED and cold tumescent anesthesia are critical points. Laser fiber design probably has a significant effect on treatment success in the performance of EVLT and also how the energy is delivered (pulsing or continuous mode) and the pull-back rate of the laser fiber are possible factors affecting complication ratios and pain scores, regardless of the type of wavelength used.

A meta-analysis of the association of obesity with abdominal aortic aneurysm presence.

Abstract: Aim The aim of this paper was to determine whether obesity is associated with abdominal aortic aneurysm (AAA) presence. We performed the first meta-analysis of currently available studies. Methods MEDLINE and EMBASE were searched through January 2014. Eligible studies were comparative studies comparing body mass index (BMI) in patients with AAA to that in subjects without AAA or estimating a relative risk of AAA prevalence for subjects with obesity (high BMI). Results Of 183 potentially relevant articles screened initially, 19 eligible studies enrolling 29,120 patients with AAA and 3,163,575 subjects without AAA were identified and included. A pooled analysis demonstrated no statistically significant difference between BMI in the AAA group and that in the control group: mean difference, 0.46 kg/m2; 95% confidence interval, -0.07 to 1.00 kg/m2; P=0.09. Another pooled analysis demonstrated that obesity was unassociated with a statistically significant increase in AAA prevalence: odds ratio, 1.07; 95% confidence interval, 0.94 to 1.22; P=0.30. There was no evidence of significant publication bias: P=0.69 and 0.90 for mean difference and odds ratio, respectively. Conclusion Obesity appears to be unassociated with AAA presence.

Expression of VEGFs and its receptors in abdominal aortic aneurysm.

Abstract: AIM The development of abdominal aortic aneurysm (AAA) is thought to be related to an imbalance of VEGF and its receptors. This study aimed at evaluating the expression of VEGF family members and their receptors in AAA wall, AAA mural thrombus and normal aorta wall. METHODS AAA specimens (mural thrombus-luminal layer, mural thrombus-abluminal layer, AAA wall) were collected from 24 patients undergoing elective open AAA repair. Abdominal aortas from 12 organ donors served as controls. The expression of VEGF (VEGF-A, VEGF-B, VEGF-C and VEGF-D) and VEGF receptors (VEGFR-1, VEGFR-2 and VEGFR-3) was evaluated using Western blot. RESULTS Increased expression of VEGF-B (269±31%), VEGF-C (1065±92%) and VEGF-D (145±12%) was found in AAA wall, when compared to normal aorta (P 0.01). Mural thrombus (abluminal/luminal) expression of VEGF-A (172±22%/133±17%), VEGF-B (308±24% / 363±28%), VEGF-C (1496±110%/830±58%) and VEGF-D (200±18%/142±12%) was increased in comparison with normal aorta (P<0.01). Furthermore, VEGF-C and VEGF-D expression was increased in mural thrombus abluminal layer, when compared to its luminal layer (1496±110% vs. 830±58% and 200±18% vs. 142±12%, P<0.01). VEGFR-1 expression was increased only in luminal and abluminal layers of mural thrombus (377±58% and 2188±196%, P<0.01). In comparison with normal aorta, all aneurysm samples (AAA wall, mural thrombus abluminal and luminal layers) expressed higher levels of VEGFR-2 (565±52%, 1057±125%, 537±54%, P<0.01) and VEGFR-3 (233±18%, 197±17%, 193±16%, P<0.01). CONCLUSIONS Our study demonstrates that the abluminal layer in AAA mural thrombus contains high levels of VEGFs and VEGF receptors, suggesting that this layer may play a significant role in AAA disease pathogenesis. Increased expressions of VEGF and their receptors in AAA mural thrombus may impact different pathways involved in AAA etiology.

Mutiprobe devices for exercise transcutaneous oxymetry in patients complaining claudication: interest and limits of unusual probe positions.

Abstract: Background Exercise transcutaneous oximetry (PtcO2) can argue for a vascular origin of exercise-related pain in atypical unusual localizations, such as lumbar, thigh or foot pain. We used five probes as a standard for treadmill PtcO2 tests. Recent commercially available devices now include up to eight probes. We aimed at analyzing the potential interest of positioning a 6th probe on the area of unusual localization during exercise PtcO2 tests. Methods We retrospectively analyzed our data with a 6-probes device, using as a standard: one probe on the chest, one on each buttock and one on each calf. The sixth probe was positioned either: in the lumbar median position (N.=342), on the anterior lower part of the thigh (N.=391) or on the dorsum of the foot (N.=155) in patients complaining exercise-induced pain including the back, thigh or foot respectively. Results on the sixth probe at the limb were compared to result of the standard adjacent probe. A positive test (abnormal result) was defined as a minimal value of the DROP-index lower than minus 15 mmHg. Results Prevalence of positive results on the 6th probe with negative results on the adjacent standard probe was 2.3% at the lumbar site, 3.8% at the thigh and 12.3% at the foot level. Conclusions Atypical localizations are rarely but sometimes associated to isolated positive exercise PtcO2 results and may justify the use of more than five probes in some patients, specifically for foot pain.

Ethylene-vinyl alcohol polymer trans-arterial embolization in emergency peripheral active bleeding: initial experience

Abstract: Aim The aim of this paper was to evaluate the efficacy, safety, and clinical outcomes of superselective embolization using ethylene-vinyl alcohol copolymer (Onyx Liquid Embolic System; ev3 Neurovascular, Irvine, CA, USA) as the primary treatment in active peripheral emergency arterial bleeding. Methods Between January 2014 and June 2014, all patients with active peripheral arterial bleeding who were treated by embolization were retrospectively analyzed. We selected 15 (age 37-91 year old) patients embolized with Onyx, chosen as embolic agent in an intention-to-treat fashion. Multidetector computed tomography was performed in all patients. Results Active bleeding was detected in all cases. Digital subtraction angiography confirmed CT findings in all cases. The causes of bleeding were traumatic in 8 patients, angiodysplasia in 1 patient, duodenal ulcer in 1, chronic pancreatitis in 1 and unknown in 4 patients. Nine patients were under anticoagulant or antiplatelet therapy. Embolization was possible in all patients. The technical success rate was 100%. The immediate bleeding control rate was 100%. No rebleeding at 30 days occurred (0%). There were no major complications, or deaths attributable to the treatment. No patient needed surgery or new embolization during a mean follow-up period of 5.1 months (range, 4.5-6 months). Conclusion Control of massive active peripheral emergency arterial bleeding using superselective embolization with Onyx is feasible and safe.

Surgical and endovascular intervention on internal carotid artery near occlusion.

Abstract: Therapeutic strategy for treating carotid artery near occlusion (CANO) has been controversial. The aim of this study was to review the literature concerning the invasive treatment of atherosclerotic CANO. A review was conducted of the English medical literature from 1980 to 2013 using PubMedand EMBASE database to find studies involving open or endovascular management of CANO. The search identified 20 reports describing invasive treatment of CANO encompassing 770 patients (77.7% men; mean age 66.3±5.2 years). A typical appearance of string sign was noted in nearly 60% of the patients. The vast majority (92.6%) were symptomatic. 479 (62.2%) patients underwent an open procedure, while 291 (38.8%) were treated endovascularly. The technical success rate for the endovascular procedures was 99%, while distal embolic protection devices were applied in most patients (66%). The 30 days procedural stroke rate was 2.1% and 2.4% for open and endovascular repair respectively. During a follow-up period spanning an average of approximately two years the ipsilateral cerebrovascular event rate was 5% and 1.2% for open and endovascular treatmentrespectively. Twenty five (5.2%) restenosis or occlusions were reported for the open procedures, while 13 (5.4%) were also documented for endovascular repair. The current literature concerning the invasive treatment of CANO is weak and cannot support any evidence based recommendation. The necessity to intervene as well as the best therapeutic strategy remains controversial. This review shows that the interventionon symptomatic CANO may consist a relatively safe and effective therapeutic strategy with low perioperative cerebrovascular morbidity for both treatment modalities, although durability and long-term outcomes should be further affirmed. The low incidence of this entity and the dearth of clear evidence support the need for a large multicenter registry to clarify the absolute indications for intervention and define the best therapeutic approach.

Cold climate could be an etiologic factor involved in Raynaud's phenomenon physiopathology. Epidemiological investigation from 954 consultations in general practic.

Abstract: Aim The physiopathology of Raynaud's phenomenon (RP) is not currently fully resolved. The cold seems to be not only an important factor triggering attacks, but also inducing RP. The aims of this study were to assess the prevalence of RP in Nantes urban district, and study the relationship between RP prevalence and cold climate. Methods Patients aged between 10 and 80 years old, consulting in five Nantes General Practices, from June 2011 and March 2012, were included. Patients presenting RP underwent a full clinical examination. Subjects not meeting Allen and Brown criteria benefited from at least a dosage of Anti-Nuclear Antibodies and a naifold Capillaroscopy. Climate data provided by French national weather agency allowed establishing an average of observed temperatures during the past five years and correlating them to the observed prevalence. Results Of 954 patients included, 78 had a RP, for an overall prevalence estimated at 8.2%. The prevalence among women (8.9%) was slightly higher than men (7.3%). Secondary form represented 5.1% of RP. In the RP group, 13 patients were active smokers, mean BMI was 22.3±3.2 kg/m², and only 4 patients were treated by vasoconstrictor therapy. According to French national weather agency, between 2007 and 2011, mean temperature of January in Nantes area was 5.8 °C. Conclusion We confirmed that the lower winter temperatures a region experiences, the higher the prevalence of RP, thus raising the question of the physiopathological role of the cold in the induction or in the revelation of RP.

Recurrent varicose veins: causes and neovascularisation. A 17-year experience.

Abstract: AIM The aim of the paper was to determine the causes of varicose vein recurrence and, when neovascularisation is suspected, to confirm or exclude its presence and to establish its contribution to the recurrence of varicose veins. METHODS A retrospective analysis of a set of 217 legs reoperated in our department over a period of 17 years with a two-year prospective histological and histochemical (nestin) analysis of resected veins. RESULTS Reflux as a cause of varicose vein recurrence was identified in 93% of the limbs. It was most commonly found in the area of the saphenofemoral junction, followed by the area of the saphenopopliteal junction. Reflux in the perforating veins was almost invariably linked to that in the saphenofemoral junction or saphenopopliteal junction; an isolated damage to the perforating veins was only present in three limbs. Histological and histochemical analysis was performed for the samples of eleven veins in which neovascularisation was suspected based on preoperative duplex ultrasonography evaluation. Neovascularisation was confirmed in none of these veins and none of them was the cause of recurrence. CONCLUSION The major cause of varicose vein recurrence is a reflux left unresolved during the primary surgery, particularly in the area of the saphenofemoral junction. A less common cause is progression of the disease and the occurrence of a new reflux. Neovascularisation is of no importance for the recurrence of varicose veins.

Automated calcium burden measurement in internal carotid artery plaque with CT: a hierarchical adaptive approach.

Abstract: Aim Calcium burden measurement in internal carotid artery (ICA) plaque could play an important role in assessing stroke risk and stenosis quantification in the ICA. We propose an automatic method for labelling calcified plaques in ICA in CT images. Methods Our approach builds upon the mean shift paradigm via an adaptive thresholding strategy. The data consists of single CT slices from 75 patients, with variety of plaque sizes and number of calcium regions. The manual measurements were carried out by a neuroradiologist for benchmarking. The calcium burden was measured as the area of the labelled plaque. Various metrics were employed to compare manual and automated measurements including correlation coefficient (CC), dice similarity (DS), Jacard Index (JI), polyline distance metric (PDM) and precision of merit (PoM). Results We found that our automated method of calcium area characterization performed accurately compared to manual measurements with CC=0.978, and PoM=0.915. The PDM, DS, and JI, also indicate a good performance with a mean DS=0.85 (SD=0.085), a mean JI=0.747 (SD=0.12), and a mean PDM=0.195 (SD=0.177). Conclusion The proposed approach for calcium burden measurement, yields reasonably accurate labelling of calcified plaque when benchmarked against manual measurements. The approach is independent of the number and size of calcium regions, and the prototype design shows encouraging results to be adaptable to clinical practice.

Comparison between insulin resistance indices and carotid and femoral atherosclerosis: a cross-sectional population study.

Abstract: AIM The aim of this study was to investigate the association between commonly used insulin resistance (IR) indices and the presence and extent of carotid and femoral atherosclerosis in a general population setting. METHODS Cross-sectional analysis of 762 volunteers from the ongoing epidemiological Cyprus Study (46.6% male; mean age=60.5±10.2). 1) Carotid intima-media thickness (IMTcc), 2) carotid and femoral atherosclerotic plaque presence, 3) total plaque area in the carotid/femoral bifurcations (sum of the largest plaques in each carotid/femoral bifurcation-SPAcar/fem), and 4) total plaque area in both carotid and femoral bifurcations (sum of the areas of the largest plaques present in each of the four bifurcations-SPA) were measured using ultrasound at baseline. The HOMA-IR, QUICKI and McAuley indices as well as fasting insulin levels were estimated and their quartiles were used in linear and logistic regression analysis. RESULTS All IR indices studied were strongly associated with IMTcc (P<0.01for all) even after adjustment for age and sex and exclusion of diabetic subjects. However, when looking at plaque presence and size (i.e.area) only the HOMA-IR and especially the McAuley Index were associated with both carotid plaque presence (ORadj=1.17; 95%CI=1.01 to 1.36; P=0.03 and ORadj=0.86; 95%CI=0.74 to 0.99; P=0.04 respectively) and area (ORadj=0.10; 95%CI=0.008 to 0.20; P=0.03 and ORadj=-0.11; 95%CI=-0.20 to -0.009; P=0.03 respectively), after adjustment. The McAuley Index remained a significant predictor of both carotid plaque presence and area even after exclusion of diabetic subjects (P=0.04). CONCLUSION Our results show that while all indices were associated with carotid IMT, supporting a strong role for IR in intimal-medial thickening, only the HOMA-IR and especially the McAuley Index were associated with both carotid plaque presence and area, after adjustment. This highlights the importance of including triglyceride levels in estimating the risk for atherosclerotic plaque in the carotids as well as the possible differences in determinants for atherosclerosis between arterial sites.