Endovascular intervention for infrapopliteal chronic arterial occlusive disease

Abstract: This study aims at determining the effectiveness of infrapopliteal [IP] percutaneous transluminal angioplasty [PTA] techniques for treatment of infrapopliteal Peripheral arterial disease [PAD]

Methods: This study is a case series, combined prospective and retrospective, including 108 limbs in 104 patients with infrapopliteal PAD of Fontaine IIb, III and IV stages/ Rutherford categories 3, 4, 5 and 6. Patients underwent PTA using balloon dilatation in 73.1%, bare metal stents in 17.6%, Drug eluting balloon in 7.4%, and Drug eluting stent in 0.9% between February 2009 and January 2015

Results: Technical success was 94.2%. Primary patency at 3, 6, 12, 24 months are 92.9%, 79.3%, 69.5%, and 58.3% respectively, and was adversely affected by smoking [p=0.005]. Limb salvage at 1 year was 92.6%, and was adversely affected by smoking [p=0,027], diabetes [p=0.009], and Updated TASC II [p=0.023]

Conclusion: Infrapopliteal PTA is a safe, successful, and effective technique for treatment of critical limb ischemia, with an excellent technical success rate, good limb salvage rate, and a low pen-procedural morbidity and mortality

Management of traumatic upper limb arterial injuries: three years study

Upper limb vascular injury conditions requiring surgical intervention are multivarious and so are the surgical techniques employed. In the developing countries traumatic events predominate and the mechanism by which varies from society to another. Upper limb vascular injury must be approached promptly to avoid debilitating morbidity and mortality. is to assess the current management approach and to evaluate the outcome of patients with upper limb vascular trauma in Assiut University hospital. Forty two patients requiring operative intervention for upper limb vascular trauma from October 2009 - October 2012 were included. Patients were underwent full physical examination and resuscitation. The diagnosis of vascular injury is initially made by clinical examination as part of the full trauma assessment, plain x-ray, Doppler, Duplex and CT-angiography when indicated. Types of vascular repairs, orthopedic fixation, nerve repair, fasciotomy procedure and state of limb function after management were recorded. Forty two patients [37 males and 5 females] with mean age of 27H2.6 years [range 1.5 -70 ys] were included. The right upper limb was affected in 22 patients and the left was affected in 20 patients. Brachial artery was the most frequently affected 57.1%, followed by the axillary artery 31%, subclavian artery 9.5% and the ulnar artery 2.4%. The patients were presented 1-10 hours after injury [mean 6 +/- 2.1 hrs] with bleeding in 42.9%, ischemia 30.9%, ischemia 4 bleeding 9.5%, ischemia + hematoma 7.2% and expansile hematoma 9.5%. Penetrating trauma was in 90.4% and blunt trauma was in 9.6%. Injury by fire arm was in 40.4%, sharp objects 26%, motor car and train accidents 21%, iatrogenic 2.1% and fall from height 9.5%. Concomitant vein and/or nerve injuries were in 73%. Isolated nerve injury [brachial plexus or median nerve] was in 9.5%, isolated vein injury in 7.2% and both were injured in 57%. Orthopedic injuries occurred in 33% [open fracture 19%, closed fracture 12% and dislocation 2.4%]. Orthopaedic repair was done firstly before vascular repair except in delayed cases. Arterial repair in the form of end to end anastmosis in 42.8%, interposition vein graft 33.4%, simple repair 12%, ligation 4.7%, or thromboembolectomy in 4.7% were done. Heparin was applied both intralesional and systemic. Prophylactic fasciotomy with other vascular repair was also done in 30%. Primary nerve repair in non thermal [firearm] injuries was obtained while delayed repair was decided in thermal injuries. Small veins are ligated and large veins are managed by simple repair. The success rate of vascular repair was 39/42 [92.8%] assessed by the return of distal pulses at the end of the operation and limb salvage in follow up period. Three patients [7.2%], one of them [2.4%] died because of major head injury and above elbow amputation was done for the other two [4.8%]. All surviving patients were followed for one year for hand function and distal pulse. Clinical examination of the injured upper limb is a reliable diagnostic approach for evaluation of the vascular injury. Factors could help promoting good prognosis are; not wasting time with preoperative diagnostic tests, early intervention within 10 hours after trauma, performing orthopaedic repair firstly before vascular repair except in delayed cases, assessment and management of nerve injuries, use of intralesional and systemic anticoagulants, and prophylactic fasciotomy performance

Non invasive management of haemangioma using intralesional bleomycin injection [IBI]

Vascular anomalies like haemangiomas are among the most common forms of congenital and neonatal dysmorphogenesis. Various treatment regimens have been documented including laser therapy, sclerotherapy, embolization, surgical resection or sometimes combination of these. Percutaneous sclerotherapy was developed as a minimally invasive treatment modality for these lesions. The aim of this study is to evaluate the effect of intra-lesional bleomycin injection [IBI] in management of haemangiomas as a sclerosing therapy. 45 patients [29 female and 16 male] aged [6 months - 3 years] presented with haemangioma were studied between August 2007 and February 2012. Patients were subjected to IBI and its effect was evaluated. Patients under six months of age or with recurrent haemangioma were excluded from the study. Complete resolution [excellent] in 27 patients [60%], marked improvement [good] in 10 patients [22.2%], mild improvement [fair] in 6 patients [13.3%] and poor in 2 patients [4.4%]. Complications were recorded in 13 [28.7%] of patients. Local complications were pain and swelling in 6 [13.3%], superficial ulceration in 4 [8.8%] and scaring in 1 [2.2%]. Systemic complication in the form of flu-like symptoms was recorded in 2 [4.4%] of patients. None of the patients presented with haematological toxic effects or signs of pulmonary involvement. During the follow up period [6 to 18 months] all treated cases did not have re-enlargement or recurrence of their lesions. IBI is an effective treatment in haemnangiomas. It obviates the need for invasive primary surgery or other systemic treatment regimens

Efficacy of preoperative duplex scanning in planning for infrainguinal revascularization procedures

To evaluate safety and efficacy of preoperative duplex scanning in planning for infrainguinal revascularization procedures. Thirty patients [mean age 70 years] underwent elective DSA of lower extremity arteries at the Vascular and Endovascular Surgery unit of Perugia, Italy and were included in the study. Duplex evaluation of arterial lesions was performed for the site and degree of severity. Results were compared with DSA serving as the standard reference. Our study showed that duplex was able to determine significant lesions [either critical stenosis or occluded segments] in the femoral region with an overall sensitivity and specificity of 96.5% and 93.3% respectively and 77.7% and 99.1% as the positive predictive and negative predictive values respectively. At the popliteal region, we estimated the sensitivity and specificity as 84% and 89.2% respectively and 75% and 93.5% as the positive and negative predictive values. The overall accuracy measurements of duplex scanning at the region of leg vessels were 82.9%, and 89.4% for combined anterior and posterior tibial arteries. It seems feasible to perform infrainguinal arterial reconstructions, without preoperative angiography. Technical limitations of duplex scanning leading to inaccurate assessment of the inflow and outflow arteries, or non-visualized distal runoff arteries, should prompt angiographic evaluation

Comparative study between transposed brachiobasilic and synthetic graft brachioaxillary arteriovenous fistula in patients with chronic renal failure

The long-term survival and quality of life of patients on hemodialysis [HD] is dependent on the adequacy of dialysis via an appropriately placed vascular access. Complications of various vascular accesses in HD increase a risk of morbidity and mortality; therefore, an arteriovenous fistula [AVF] is preferable. Transposed brachiobasilic AVF and synthetic graft brachioaxillary AVF are commonly used. Follow up of fistulas by vein mapping and screening techniques for early detection of arteriovenous graft stenosis is essential because dysfunctions of these fistulas are common cause of recurrent hospitalizations. Is to compare transposed brachiobasilic AVF and polytetrafluoroethylene synthetic graft brachioaxillary AVF for hemodialysis regarding their function and complications. Patients and methods: Sixty-six patients [thirty five males and thirty one females] aged 23-71 years [48 +/- 5.9 years] with chronic renal failure for regular HD were included in the study. They were divided into two groups each of them was thirty-three patients. The first group was subjected to transposed brachiobasilic AVF and the other group was for polytetrafluoroerhylene [PTFE] synthetic graft brachioaxiIlary AVF. Patients were subjected to CBC, prothrombin time and concentration, renal function tests, blood sugar, ECG and chest x ray for preoperative fitness. Upper limb phlebography, to visualize basilica, axillary and proximal veins, w m done for all patients. Patients with complete exhausted all veins of the upper limbs [basilic, axillary and central veins] diagnosed by phlebography or patients with impalpable brachial arteries pulsations were excluded from the study Follow up of the patients were reassessed after the surgical maneuvers both clinically [palpable thrill and audible machinery murmur] and hemodynamically by Doppler study [transmitted waves through the fistula] immediately after the surgery then one month and six months later. Fifty-nine patients only were followed after six months [31 patients with transposed brachiobasilic AVF and 28 with synthetics graft brachioaxillary AVF] because of seven deaths. In patients with transposed brashiobasilic AVF, success rate was 90% immediately and 81% one month after maneuver and was 87% and 81% respectively in patients with synthetics graft polytetrafluoroethylene [PTFE] brachioaxillary AVF, after six months transposed brachiobasilic A VF success rate was 81% significantly higher than that of patients with synthetics graft brachioaxillaty AVF [71%] p<0.05. Complications were recorded in 22.4% of patients with transposed brachiobasilic AVF significantly lower than those in patients with synthetics graft brachiowillaty AVF [46%] p<0.05. The complications were thrombosis, infection, pseudoaneulysm, bleeding and insufficient distal arterial flow [steal]. Thrombosis and infection were significantly lower in patients with transposed brachiobasilic AVF [6.4% and 3.2%] than those in patients with synthetics graft brachioaxillary AVF [17.8% for each] p<0.05 for each. In patients requiring long-term haernodialysis when all their superficial veins are exhausted the choice runs between transposed brachioalasilic AVF and synthetics graft brachioaxillary A VF for the vascular access. Transposed brachiobasilic AVF carries better patency rate and less complication than synthetics graft brachioaxilfary AVF. So it can be considered the first choice for access synthetics graft brachioaxillary AVF can be utilized only when the basilic vein is not patent assessed by phlebography. Both clinical and Doppler assessment can be used in evaluation of the fistula function and complications

Erectile dysfunction: Current diagnosis and risk factors in Upper Egypt

Erectile dysfunction [ED] has taken an increasing importance in andrology and vascular practice. Recognizing the pathological pattern of ED assists in choosing the best method of treatment Normal erectile function needs good arterial inflow for adequate volume expansion of the cavernously sinusoids, sufficient to cause restriction of venous outflow and retention of the penile blood flow. Color flow Doppler analysis after intra-cavernous injection of vaso-active drugs has been reported to be a minimally invasive, accurate method, and considered to be the gold-standard technique for evaluating penile hemodynamics. It becomes one of the useful diagnostic methods for evaluation of ED. to diagnose types of erectile dysfunction and to evaluate the risk factors. From january to August 2006, 280 married patients with ED referred from andrology and vascular surgery clinics to radiology department, of Assiut University Hospital to be included and diagnosed according to International Index of Erectile Function. They aged from 21-63 years and age >40 were considered a risk factor. Full history and clinical examination [including vascular examination of peripheral blood vessels and examination of the external genitalia] was done. Pharmacodynamics color Doppler was done to all patients using Acuson XP/10 machine, and 7 MHz frequencies transducer. Gray scale and color Doppler imaging was performed to the penis to visualize the anatomic details of the corpora cavernosa, cavernosal arteries and surrounding structures. Vaso-dilating agent 20 micro g prostaglandin E1 [PGEI] was injected directly into the corpus cavernosma. Peak systolic velocity [PSV] and end diastolic velocity [EDV] of the cavernosal artery was measured. The resistivity index [Rl] was readily calculated by the machine and given. Description of sildenafil citrate [Viagra] 50 mg orally for six coitus times in all patients was done and they were objectively reevaluated. Patients with peripheral arterial diseases, Leriche syndrome or ischemic heart disease were excluded from the study. Patients mean age was 37.68 +/- 10.85 years and was from 4 months to 15 years and the mean duration of impotence was 3.92 +/- 4.06 years. History of risk factors as smoking was present in 47%, age > 40 years in 35% diabetes in 28%, and drugs induce impotence in 10% of ED patients. Normal Doppler-findings were present in 67.8% of ED patients and were diagnosed non-vasculogenic ED [psychogenic in 32.2 %, idiopathic in 28.5% and neurogenic in 7.1 % of ED patients]. .Abnormal Doppler findings were present in 32.2% of ED patients and were diagnosed as vascurlogenic ED [13.5% of total ED patients were venogenic, 10.5% were arteriogenic and 8.2% were combined ED]. vasculogenic ED patients were venogenic in 41.1%, arteriogenic in 33.3% and combined in 25.6% of them. Doppler study showed a significant decrease ii cavernously artery PSV and RI and a significant increase m EDV values in vasculobogenic group than those of total patients and non-vasculogenic group. Arteriogenic group showed a significantly lower PSV values and venogenic group showed a significantly lower. RI and significantly higher EDV values than those of non-vasculogenic group. No significant difference was present in-between non-vasculogenic groups regarding their Doppler values. Sildenafil citrate [Viagra] response was present in all patients and varies between grade II in 21.6% and grade III and lV in 78.4% of ED patiens. Vasculogenic and psychogenic ED got response in 100% of them. Idiopathic and neuogenic ED response was in 70% and 40% of them respectively. Erectile dysfunction could be vasculogenic or non-vasdogenic as psychogenic, idiopathic, or neurogenic. Pharmacodynamic color Doppler using PGE1 is diagnostic, safe and minimally invasive method to differentiate vasculogenic from nonvasculogenic typs. Risk factors concerned in ED are diabetes, smoking and some drugs. Sildenafil citrate can give good result with vasculogenic and psycogenic and to less extent with idiopathic and neurogenic ED

Early detection of macro vascular diseases of carotid and femoral arteries in patients with Rheumatoid arthritis

Rheumatoid arthritis [RA] is a multi-system disorder with inflammatory process associated with increased cardiovascular risk. The duplex scanning is a noninvasive technique to detect early atherosclerotic plaques and arterial wall changes either in symptomatic or asymptomatic patients. Early detection of asymptomatic vascular disorders allows early intervention and possibly retards the development of symptomatic cardiovascular diseases. A higher risk of cardiovascular morbidity and mortality persists among patients with an abnormal ankle brachial index [ABI] and it is useful to identify asymptomatic patients with established disease. To detect the early manifestations of atherosclerotic changes of carotid and femoral arteries in patients with rheumatoid arthritis. Twenty-four patients with chronic rheumatoid arthritis [six males and eighteen females] aged 26-65 years [45.7 +/- 14.7 years] with mean disease duration 11.12 +/- 6.4 years [2-18 year] were included in the study. All patients were on methotrexate, corticosteroids and nonsteroidal anti-inflammatory lines of treatment. Twenty apparently normal subjects were included in the study as controls. Patients with other types of collagen diseases or patients with ischemic peripheral manifestations, ischemic heart disease, diabetics or smokers were excluded from the study. Full history and thorough clinical examination, including full joints and vascular examination for all peripheral arteries and calculation of ankle brachial index [ABI] was done using pocket Doppler and sphygmomanometer. Patients and controls were subjected for Hb, WBC, platelet count, rheumatoid factor, blood sugar, ESR, levels of plasma cholesterol, triglyciride, HDL and LDL. Duplex study was performed on carotid and femoral arteries. The mean ABI in patients was 1.21 +/- 0.3, non-significantly lower than controls but still within the range of normal. There was a significant increase in the levels of cholesterol, triglyciride, LDL and HDL than controls and still within the range of normal. Duplex changes of carotid and femoral arteries were present in 18/24 [75%] of patients including hemodynamic changes, intimal thickness, plaques, stenotic segment. Duplex of carotid arteries detected hemodynamic changes in 12.5%, intimal thickness, plaques and stenotic segment in 25% of patients for each and detected intimal thickness of femoral arteries in 25% of patients. There was a significant negative correlation between the ABI and duration of disease [r = - 0.506, p<0.01] and a significant positive correlation between the intimal thickness and duration of disease [r =-0.807, p<0.001]. There was no relation between drug intake or type of drug and ABI or intima thikness and there was no relation between cholesterol, triglyciride, LDL or HDL levels and ABI or intimal thickness. There is increased risk of vascular disease in RA patients involving carotid and femoral arteries in the form of hemodynamic changes, intimal thickness, plaques and stenotic segment. Low ABI together with Duplex study are helpful for detection of subclinical ischemic changes in such high-risk patients. Normal levels of plasma cholesterol, triglyciride, HDL and LDL do not exclude underlying vascular changes. So we recommend ABI and Duplex examination for all RA patients and further studies are needed to elucidate non-traditional risk factors such as endothelial dysfunction, immune activation and impaired fibrinolysis in addition to oxidative stress

Diabetic foot infection: current concepts

Diabetic foot problems are one of challenging diseases in surgical practice. They can be a major cause of disablement and have serious economic consequences for health organizations. Twenty percent of all diabetic patients are hospitalized due to foot problems at a certain time in their life. To study the various presentations, assessment, management and outcome of patients with diabetic foot infection and to plan for the future management The study included 60 patients who presented with diabetic foot infections [68 limbs]. According to Modified Wagner's classification, patients were divided into 5 grades depending on the severity of infection. Management programs and working guidelines were; pressure off- loading and non-weight bearing, control of hyperglycemia, control of infection, local wound care and dressing. Complete healing after incision and debridement was considered as an excellent result., Successful minor amputation at foot level was considered as a good result. Failure or poor results were recorded for cases with major amputations. Patient suffering from vascular lesions were excluded. Of the 68 limbs, ulceration was detected in 26 [28.2%] limbs, infection in 37 [54.4%] and osteomyelitis in 17 [25%]. The most common cultured organisms were staphylococeci [28%] followed by streptococci [20%] and pseudomonas [14%]. Mixed infection was found in 60% of the isolate. Utilized surgical incisions included web space incision, curved lateral dorsal incision, curved medial planter incision, longitudinal planter incision, transverse planter incision at the forefoot, lateral foot incision, medial foot incision, and cruciate heel incision. The overall results were good to excellent in 80.9% and poor in 19.1%. Foot ulcers and infections are serious cause of morbidity in patients with diabetes. Properly identifying and counseling persons at risk of ulceration or infection can prevent the horrible consequence such as lower extremity amputation. Aggressive and appropriate assessment and treatment of ulcers and infections together with patient cooperation decreases the morbidity of diabetic patients with sparing the foot or part of it

Approach to surgical management of carotid body tumor and our experience at Assiut University Hospital

Carotid body tumor [CBT] is a rare neoplasm, which typically presents as a slow growing, painless neck mass found along the anterior border of the sternocleidomastoid muscle. This tumor is generally benign but possesses aggressive resection remains a surgical challenge traditionally associated with a 15-30% incidence of cranial nerve injury. To present our experience at Assiut University Hospital regarding surgery of CBT and the use of preoperative embolization and mandibulotomy in large sized tumors. The study was performed on 18 cases with CBT, 5 females and 13 males with a mean age of 40 years. Clinical and radiological diagnosis was recorded. Angiography was done in 17 cases for confirmation of CBT diagnosis and its extent, evaluation of carotid arteries and for preoperative emobilization. One case due to some technical difficulties was evaluated by spiral CT angiography. Patients were classified according to the tumor size and Shamblin classification. Preoperative imobilization to decrease the tumor vascularity and the intraoperative blood loss, was done. Patients were subjected to surgical removal of the tumor through anterior longitudinal approach to the carotid system not later than 4 days after the embolization to avoid the inflammatory phase and the development of any collaterals. Paramedian mandibulotomy was done in cases with very large tumore. Patttients presented with painless swelling, local tenderness, bruit, difficulty with swallowing, and hoarseness. Preoperative embolizaiton for large cases decreases the tumor vascularity by [25% to 45%][as documented by post embolization films. The average blood replacement was one unit. There were no deaths and complications were recorded in 44.4% of patients as vascular complications [legation of external carotid artery, simple repair of internal carotid artery, and repair of internal carotid artery with interposition of vein graft] or neurological complications as cerebrovascular stroke, injury of vagus, hypoglossal and marginal mandibular nerves. All cases were confirmed histologically as benign paragangliomas. CBT should be taken in considerations in all lateral neck masses. Angiograhy is very helpful in making the diagnosis. Preoperative embolizaiton decreases the tumor size, the vascularity and facilitates the subsequent surgery. Paramedian mandibulotomy provided a wide exposure, in cases with large sized tumors. Early detection and resection of smaller tumors ultimately reduced the risk of complications