Stents in the femoropopliteal territory: prevalence of fractures and their consequences / Stents no território fêmoro-poplíteo: prevalência de fraturas e suas consequências

ABSTRACT Endovascular treatment for femoropopliteal arterial disease has made revascularization procedures less invasive, but the self-expanding stents used can suffer great wear in arteries with extreme mobility. Objective: to evaluate the prevalence of fractures in stents implanted in the femoropopliteal segment, to identify predisposing factors and consequences on arterial patency. Method: between March and June 2019, thirty patients previously operated for femoropopliteal obstruction underwent stent X-rays in anteroposterior and lateral views to detect fractures and Doppler to analyze arterial patency. Results: we observed 12 cases with fractures (33.3%): 1 type I (2.8%), 3 type II (8.3%), 5 type III (13.9%), 3 type IV (8.3%) and no type V. According to the TASC II we had 1 in group B (8.3%), 6 in group C (50%) and 5 in group D (41.6%) p <0.004. The number of stents per limb was 3.1 (± 1.3) in cases of fracture versus 2.3 (± 1.3) in cases without fracture (p = 0.08). The extension was 274.17mm (± 100.94) in cases of fracture and 230.83mm (± 135.44) in cases without fracture (p = 0.29). On Doppler we had: 17 patients (47.2%) without stenosis, 9 patients (25%) with stenosis> 50% and 10 patients (27.8%) with occlusion (p = 0.37). There was no correlation between fracture and arterial obstruction (p = 0.33). Conclusion: stent fractures are a frequent finding in the femoropopliteal area (33.3%), being more prevalent in cases of more advanced disease (C and D). There was no association between the finding of fracture and arterial obstruction.

RESUMO Os tratamentos endovasculares para a doença arterial obstrutiva fêmoro-poplítea tornaram os procedimentos de revascularização menos invasivos, porém os stents metálicos autoexpansíveis utilizados podem sofrer grande desgaste em artérias com extrema mobilidade. Objetivo: avaliar a prevalência de fraturas em stents implantados no segmento fêmoro-poplíteo, identificar fatores predisponentes e possíveis consequências sobre a patência arterial. Métodos: entre março a junho de 2019, trinta pacientes previamente operados por obstrução fêmoro-poplítea realizaram RX dos stents em incidências ântero-posterior e perfil para detectar fraturas e eco Doppler para analisar a patência arterial. Resultados: observamos 12 casos com fraturas (33,3%): 1 do tipo I (2,8%), 3 do tipo II (8,3%), 5 do tipo III (13,9%), 3 do tipo IV (8,3%) e nenhuma tipo V. Segundo a classificação TASC II, tivemos 1 no grupo B (8,3%), 6 no grupo C (50%) e 5 no grupo D (41,6%) p<0,004. O número de stents por membro foi de 3,1 (±1,3) nos casos de fratura contra 2,3 (±1,3) nos casos sem fratura (p = 0,08). A extensão tratada foi 274,17mm (±100,94) nos casos de fratura e 230,83mm (±135,44) nos casos sem fratura (p=0,29). No Doppler tivemos: 17 pacientes (47,2%) sem estenose, 9 pacientes (25%) com estenose>50% e 10 pacientes (27,8%) com oclusão (p=0,37). Não houve correlação entre fratura e obstrução arterial (p=0,33). Conclusão: as fraturas de stents são um achado frequente no setor fêmoro-poplíteo (33,3%) sendo mais prevalentes nos casos de doença mais avançada TASC II C e D. Não houve associação entre o achado de fratura e obstrução arterial.

Plants considered useful for hypoglycemic, antihypertensive or hypolipidemic treatments by patients with peripheral vascular diseases / Plantas consideradas útiles como hipoglicemiantes, antihipertensivas o hipolipemiantes por pacientes con enfermedades vasculares periféricas

INTRODUCTION: knowing patients 'believes about the medicinal utility of plants may provide a basis for educating them for a rational use of herb preparations. OBJECTIVE: to characterize the plants that are considered useful for antidiabetic, antihypertensive or hypolipidemic treatment among patients with peripheral vascular diseases. METHODS: a survey was performed among patients of the National Institute of Angiology and Vascular Surgery from February through April 2007. The characteristics of the use of plants as medicinal remedies and the names of species considered useful for the treatment of diabetes, arterial hypertension and dyslipidemia were recorded. RESULTS: two hundred and forty five both sex adult volunteers (142 female/103 male), aged 44 to 72 years) were included in the study. More than 80 % of them used medicinal plants at least occasionally and confided on their efficacy to treat different illnesses Fifteen species, mainly Allium sativum L., Citrus aurantifolia Ch., Justicia pectoralis Jacq.., Morinda citrifolia L., Ocinum sanctum L and Salvia officinalis L, from 11 botanical families, were mentioned by participants. Most patients' claims about plants´ properties have been scientifically supported in some extent, nevertheless, the majority of the pharmacological evidence relays on pre-clinical studies and results of clinical trials are not conclusive. The lack of standardized plant preparations with identified active principles and demonstrated clinical effectiveness are limitations for recommending their therapeutic use. CONCLUSION: this study has provided the first characterization of the use of plant products by patients with peripheral vascular diseases for medicinal purposes and confirmed that physicians should be aware about the possibility of herb-drug interactions that should be diagnosed. This information would aid the scientifically supported integration of Phytotherapy to the clinical practice.

INTRODUCCIÓN: el conocimiento tradicional de los pacientes sobre la utilidad de las plantas medicinales puede servir de base para su educación en el uso racional de las preparaciones herbarias. OBJETIVO: caracterizar las plantas que los pacientes con enfermedades vasculares consideran útiles para el tratamiento de la diabetes, la hipertensión y como hipolipemiante. MÉTODOS: se realizó una encuesta a los pacientes del Instituto Nacional de Angiología y Cirugía Vascular entre febrero y abril de 2007. Las características del empleo de las plantas con fines medicinales y los nombres de las especies consideradas útiles para tratar la diabetes, la hipertensión arterial y la dislipidemia fueron tabulados. RESULTADOS: doscientos cuarenta y cinco adultos voluntarios de ambos sexos (142 femeninos/103 masculinos, edad 44 a 72 años) fueron incluidos en el estudio. Más del 80 % de ellos utilizaban las plantas medicinales al menos ocasionalmente y confiaban en su eficacia para tratar diferentes enfermedades. Quince especies, fundamentalmente Allium sativum L., Citrus aurantifolia Ch., Justicia pectoralis Jacq., Morinda citrifolia L., Ocinum sanctum L. y Salvia officinalis L., pertenecientes a 11 familias botánicas, fueron mencionadas por los participantes en la encuesta. La mayoría de los planteamientos de los pacientes sobre las propiedades de estas plantas tienen algún fundamento científico, sin embargo, las evidencias farmacológicas disponibles son fundamentalmente de tipo pre-clínico y los resultados de los ensayos clínicos efectuados no son concluyentes. La carencia de preparaciones derivadas de plantas estandarizadas, con principios activos identificados y efectividad clínica demostrada, son limitaciones para recomendar su utilización terapéutica. CONCLUSIONES: esta es la primera caracterización del uso de productos de plantas con fines medicinales por pacientes con enfermedades vasculares periféricas, y confirma que los facultativos deben conocer sobre la posibilidad de interacciones planta-medicamento que deben ser diagnosticadas. Esta información ayudaría a la integración de la Fitoterapia a la práctica clínica sustentada científicamente.

Comparação entre os métodos subjetivo e objetivo para avaliação da capacidade funcional durante tratamento clínico em pacientes com claudicação intermitente / Comparison between subjective and objective methods to assess functional capacity during clinical treatment in patients with intermittent claudication

OBJETIVO: Verificar se há relação entre a medida da capacidade funcional avaliada subjetiva e objetivamente em relação ao estado atual e após tratamento clínico em pacientes com claudicação intermitente. MÉTODOS: Foram recrutados 500 pacientes com claudicação intermitente. Todos realizaram exame clínico e foram submetidos a uma avaliação funcional por meio do método subjetivo (consulta clínica) e objetivo (teste de esteira). Adicionalmente, 50 pacientes foram selecionados para se avaliar o efeito do tratamento clínico, pelos métodos subjetivo e objetivo, em relação à capacidade funcional. RESULTADOS: Dos 500 pacientes selecionados, somente 60 (12,0%) apresentaram valores referidos e observados similares. Os demais pacientes, ou seja, 440 (88,0%) apresentaram valores relatados discordantes em relação àqueles obtidos no teste de esforço. Com relação ao efeito do tratamento clínico em relação à capacidade funcional, os resultados foram similares entre ambos os métodos (χ²=1,7; p=0,427). CONCLUSÃO: Apesar de o método subjetivo superestimar os valores de capacidade funcional, quando comparados ao método objetivo, não foram observadas diferenças significantes entre ambos os métodos, quando se analisou o efeito do tratamento clínico. Assim, o método subjetivo fornece informações similares em comparação à medida objetiva no acompanhamento do tratamento clínico de pacientes com claudicação intermitente.

OBJECTIVE: To analyze if there is any relation between functional capacity assessed by subjective and objective methods regarding the current state and after clinical treatment in patients with intermittent claudication. METHODS: A total of 500 patients with intermittent claudication were enrolled. All patients underwent clinical examination and a functional evaluation by subjective (clinical visit) and objective method (treadmill test). Additionally, 50 patients were selected to evaluate the effect of clinical treatment by subjective and objective methods in relation to functional capacity. RESULTS: Out of 500 patients, only 60 (12.0%) had similar results in both methods. The remaining, that is 440 patients (88.0%) had subject values in disagreement with stress test findings. Regarding the clinical effect of the treatment on the functional outcomes, results were similar in both methods (χ²=1.7; p=0.427). CONCLUSION: Although the subjective method overestimates the functional capacity when compared to the objective method, no significant differences were observed between both methods when analyzing the effect of clinical treatment. Thus, the subjective method provides similar information as compared with objective method, in monitoring the clinical treatment of patients with intermittent claudication.

Glomangioma da artéria digital do polegar: relato de um caso / Glomus tumor of digital artery of thumb: case report

Os autores relatam um caso de tumor glômico em ramo da artéria radial que irriga o polegar direito, com história clínica de 4 meses. O doente referia o aparecimento de tumoração de aproximadamente 2,0 centímetros na região interdigital, entre o primeiro e o segundo quirodactilos da mão direita, sobre o músculo flexor curto do polegar, extremamente dolorosa e com dor em progressão. Os exames com aparelho de Doppler bidirecional e o eco-color-Doppler apresentaram, como diagnóstico presuntivo, malformação arteriovenosa, pelo turbilhonamento do fluxo e ausência de estenoses. A tumoração foi retirada por cirurgia aberta e encaminhada para exame histopatológico, com diagnóstico de glomangioma. Este relato descreve uma doença arterial pouco frequente, que causa extremo desconforto ao seu portador, mas que é solucionada pela exerese cirúrgica, sem sequelas.

We report on a case of glomus tumor in the branch of the radial artery of the right thumb. The tumor had a 4-year clinical history. The patient reported the development of a 2.0-cm tumor in the interdigital region between the first and second fingers of the right hand on the short flexor muscle of thumb. The patient also complained of severe and progressive pain. Tests using bidirectional Doppler and echo-color-Doppler revealed a presumptive diagnosis of arteriovenous malformation based on the turbulence of the flow and absence of stenosis. The tumor was removed by open surgery and sent for histopathological examination, which showed a diagnosis of glomangioma. The present report describes a rare arterial disease causing extreme discomfort to the patient, which may be treated with surgical resection without sequelae.

Nuevo enfoque para el tratamiento de las causas de ateroembolia / New approach in the treatment of the causes of ateroembolism

La ateroembolia es una entidad poco conocida y cuyo pronóstico es sombrío, especialmente en aquellos cuadros de ateroembolia diseminada, pero también en casos de ateroembolia distal que provoca un síndrome inflamatorio de respuesta sistémica. Durante 14 años recopilamos 31 casos de ateroembolia, 5 de ellas postoperatorias y 26 casos con orígenes distintos: 20 debido a aorta Shaggy y 6 a otras causas. De las 20 con aorta Shaggy, 10 presentaban ateroembolia. 22 de los 26 casos no iatrogénicos fueron tratados por vía endovascular, con una mortalidad del 9%. De acuerdo a nuestras observaciones, comentamos nuestra conducta y las variaciones en el tratamiento, proponiendo una clasificación que contemple los casos asintomáticos para el tratamiento precoz de estas lesiones aórticas, antes de producir complicaciones severas por ateroembolias o síndromes isquémicos de los miembros inferiores. Asimismo, comentamos aquellos trucos que aprendimos con la observación de los distintos casos reseñados.

A ateroembolia é uma entidade pouco conhecida e cujo prognóstico é sombrio, especialmente em quadros de ateroembolia disseminada, mas que também ocorre em casos de ateroembolia distal, o que provoca uma síndrome inflamatória de resposta sistêmica. Durante 14 anos recolhemos 31 casos de ateroembolia. 5 deles, postoperatórias e 26 casos com origens diferentes: 20 devido à aorta Shaggy e 6 por outras causas. Das 20 com aorta Shaggy, 10 apresentavam ateroembolia. 22 dos 26 casos não iatrogênicos foram tratados via endovascular, com uma mortalidade de 9%. De acordo com as nossas observações, comentamos as condutas e variações no tratamento, propondo uma classificação que inclua os casos assintomáticos para o tratamento precoce destas lesões aórticas, antes de produzir complicações severas por ateroembolias ou síndromes isquêmicos dos miembros inferiores. Comentamos os truques que aprendemos com a observação dos diferentes casos selecionados.

Ateroembolism is not a very well known entity and its prognosis is poor, especially in cases of disseminated ateroembolism, and also in cases of distal ateroembolism which causes aninflammatory syndrome of systemic response. 31 cases of ateroembolism were registered during 14 years, 5 were post-surgical and 26 due to different etiologies: 20 due to shaggy aorta and 6 due to other reasons. Of the 20 cases with shaggy aorta, 10 presented ateroembolism. 22 of the 26 non-iatrogenic cases were treated with the endovascular approach with a 9% mortality. According to our observations, we discussed our approach and treatment options, suggesting a classification which includes asymptomatic cases for early treatment of these aortic lesions, before they induce severe ateroembolic complications or lower limb ischemic syndromes. Likewise, we discuss some tips learnt during the observation of the different cases commented.

Angioplasty of a persistent sciatic artery: case report / Angioplastia de artéria isquiática persistente: relato de caso

Transluminal balloon angioplasty is a good choice for the treatment of lower limb arterial occlusion. Although there are some guidelines addressing its indications, some situations are so unusual that there is no consensus on their management. The presence of a persistent sciatic artery is a rare congenital anomaly of the circulatory system and may be associated with early atheromatous degeneration and occlusion. The authors describe the case of an 81-year-old woman that presented with a history of rest pain, atrophic lesion and no distal pulses. Angiogram depicted a persistent sciatic artery with segmental occlusion and distal disease. The therapeutic option was balloon angioplasty of the occluded segment, with technical and clinical success at mid-term follow-up.

A angioplastia transluminal com balão tem se mostrado uma boa alternativa no tratamento de oclusões arteriais em membros inferiores. Embora já existam algumas diretrizes quanto à sua indicação, algumas situações ainda são inusitadas e carecem de consenso pela sua raridade. A presença de artéria isquiática persistente é uma anomalia congênita rara do sistema circulatório e pode estar associada com doença ateromatosa precoce e oclusão. Os autores apresentam um caso de uma paciente do sexo feminino de 81 anos, com história de dor de repouso, lesão trófica e ausência de pulsos distais. A arteriografia mostrou persistência de artéria isquiática com oclusão segmentar e doença distal. A abordagem terapêutica escolhida foi angioplastia do segmento ocluído, e o seguimento de médio prazo mostrou sucesso técnico e clínico com esta técnica.

Complicações macrovasculares do diabetes melito: peculiaridades clínicas, de diagnóstico e manejo / Macrovascular diabetic complications: clinical characteristics, diagnosis and management

O diabetes melito (DM) é um fator de risco independente para doença arterial coronariana, acidente vascular cerebral, doença vascular periférica e insuficiência cardíaca, que são as principais causas de morte nesses pacientes. Além disso, pacientes com DM e doença cardiovascular têm pior prognóstico, por apresentarem menor sobrevida, maior risco de recorrência da doença e pior resposta aos tratamentos propostos. Os avanços diagnósticos e terapêuticos das últimas décadas já mostram uma redução do risco de eventos cardiovasculares nesses pacientes, mas o risco absoluto desses é ainda duas vezes maior em relação ao dos pacientes não diabéticos. Portanto, é prioritária a adoção de um manejo intensivo, com controle rígido dos fatores de risco cardiovasculares. Esta revisão trata das principais características clínicas e apresenta uma abordagem prática do rastreamento, diagnóstico e tratamento da doença macrovascular nos pacientes com DM.

Diabetes mellitus (DM) is an independent risk factor for coronary heart disease, stroke, peripheral arterial disease and heart failure, which are the main causes of death in these patients. Moreover, patients with DM and cardiovascular disease have a worse prognosis than nondiabetics, present lower short-term survival, higher risk of recurrence of the disease and a worse response to the treatments proposed. In the last decades, diagnostic and therapeutic progress had already shown benefits concerning cardiovascular risk reduction in these patients, but their absolute mortality risk is still twice that of non-diabetic patients. Because of this, the adoption of intensive treatment, with strict cardiovascular risk factor control, is a priority. The present study presents the main clinical characteristics and also the practical approach for screening, diagnosis and treatment of patients with diabetic macrovascular disease.

Insuficiencia arterial de extremidades inferiores / Peripheral vascular disease

La insuficiencia arterial de extremidades inferiores es la forma más frecuente de enfermedad arterial periférica. Clínicamente se presenta como un cuadro asintomático, como claudicación intermitente o finalmente como isquemia crítica de la extremidad. Esta última instancia, caracterizada por dolor de reposo, gangrena o úlcera isquémica de la extremidad, progresará hacia la amputación de no mediar una intervención. El tratamiento médico es básico en todos estos pacientes. Se deben corregir los factores de riesgo, poniendo énfasis en la suspensión del cigarrillo y buen control de la hipertensión arterial, dislipidemia y diabetes. El ejercicio de marcha supervisado es primordial. Hoy en día las opciones de revascularización son la cirugía abierta tradicional y la terapia endovascular. La decisión sobre cuál es ofrecida a los pacientes se basa en variables anatómicas de la lesión y del estado general del paciente. El ideal es tratar a todos los pacientes por vía endovascular dado la baja morbi mortalidad y rápida recuperación postoperatoria.

Peripheral vascular disease commonly affects the arteries supplying the legs. Most of these patients are asymptomatic, some complain of intermittent claudication and luckily few present with critical limb ischemia (rest pain, ulceration and gangrene). In the latter amputation is the only solution unless the limb is revascularised. Medical treatment is essential, based on control of risk factors as hypertension, diabetes and lipid disorders. All patients should be advice to stop smoking and take a supervised exercise program. Nowadays the options for revascularization are endovascular procedures and surgery. Which one is suitable for every patient depends on anatomical and patient characteristics; however the best one seems to be the endovascular procedure due to low morbidity and mortality plus fast recovery

Un año de experiencia en colgajos perforantes / One year of experience in perforator flap

El avance de la cirugía reconstructiva y especialmente de la microcirugía, nacida hace solamente tres décadas, ha sido exponencial. Hoy no sólo se busca cubrir defectos sin complicaciones vasculares, sino que el nuevo desafío es tratar de recuperar función y estética y, al mismo tiempo, conseguir la mínima morbilidad en el sitio donante. El mejor ejemplo de este desarrollo son los colgajos perforantes. Un colgajo perforante es un colgajo fascio cutáneo pediculizado únicamente por sus vasos perforantes. Su confiabilidad ha sido puesta en duda durante la última década por múltiples publicaciones que los catalogan como difíciles de realizar por el tamaño de los vasos así como por su errática anatomía. Este mito ha caído principalmente a punto de partida de publicaciones orientales y una mayor experiencia en occidente. Actualmente, el índice de supervivencia casi alcanza el 98 % debido al refinamiento de las técnicas y los instrumentos...La intención de este trabajo es mostrar nuestra experiencia en la utilización de estos colgajos, habiéndolos utilizado en una variedad de defectos tanto en reconstrucción de cabeza y cuello como de partes blandas. En el último año se han realizado en nuestra institución un total de 16 colgajos perforantes, entre ellos el más común fue el ALT (antero lateral thigh) y con menor frecuencia el DIEP (deep inferior epigastric artery perforator flap), el TAP (thoraco dorsal artery perforator flap) y el TFLP (tensor fascia lata perforator flap). La tasa de éxito fue del 94 %, con mínima morbilidad en la zona dadora.

The avance of reconstructive surgery and specially of microsurgery, born only three decades ago has been exponential. Today we not only try to cover defects without vascular complications but we try to recover function and aesthetics with minimal door site morbidity. The best example of this development have been perforator flaps. A perforator flap is fascio cutaneos flap only vascularized by it's perforators. Their viability has been doubtged because of multiple publications that catalog then as dificult to perform because of the small pedicles and their erratic anatomy. This myth has fallen mainly because of asiatic publications and more experience in western countries. Today the succes rate reaches 98 %. The intention of this paper is to show our experience performing this kind of flaps, in a variety of defects. During the past year we have perfomed at our institution a total of 16 perforator flaps, among them the most common was the ALT (antero lateral thigh) and with less frecuency DIEP (deep inferior epigastric artery perforator flap), the TAP (thoraco dorsal artery perforator flap) and the TFLP (tensor fascia lata perforator flap). The succes rate was of 94 % with minimal donor site morbidity.

measurement of serum lepoprotein [a] and apolipoprotein-B be of prognostic value in patients with type II diabetes mellitus with myocardial infarction and peripheral vascular disease?

Current clinical guidelines require that five indices [total cholesterol LDL cholesterol, HDL cholesterol triglycerides and the total/ HDL cholesterol ratio] be measured or calculated to assess the lipid related risk of vascular disease. Recently, quantification of plasma Lp [a] and Apo-B was proposed as recent clinical markers that will allow better prediction of coronary and peripheral arterial disease. This study prospectively examined whether high levels of Lp [a] and Apo-B have a significant risk and prognostic value in type II diabetic patients with myocardial infarction and peripheral vascular disease. The patients included in the study were selected properly from outpatient clinics of Vascular Surgery Unit as well as Internal Medicine Department [Cardiovascular Unit], Mansoura University. The patients were divided into 4 groups: Group I [n=15]: Type II DM with no CAD and no PVD. Group II [n=15]: Type II DM with history of myocardial infarction and No PVD. Group III [n=15]: Type II DM with no history of myocardial infarction but have symptomatic PVD. Group IV [n=15]: Type II DM with history of myocardial infarction and have PVD. Patients with acute illness or taking Niacin, Estrogen replacement or antibiotics were excluded. All patients were subjected to thorough history taking, cardiovascular and peripheral vascular system evaluation including BMI, ABJ, ECG, Doppler echocardiogram as well as peripheral vascular angiography. Laboratory evaluation of our patients include assessment of diabetic state, HbAlc, standard lipid profile parameters as well as evaluation of Lp [a] and Apo-B. Serum level of Lp [a] and Apo-B showed highly statistically significant results when comparing group I with any group of type II diabetic patients complicated with either MI or PVD [P<0.001]. However, serum apo-B level was highly significant in those complicated with PVD [P<0.001], while serum Lp[a] was statistically higher in those having myo-cardial infarction [P=0.03]. Our study revealed that elevation of serum level of both Lp [a] and Apo-B were significantly correlated with occurrence of myocardial infarction and different grades of peripheral vascular insufficiency in type II diabetic individuals. However, increased serum level of Lp[a] showed higher significant prediction for occurrence of MI while, elevation of serum level of Apo-B predict more the occurrence of PVD among our patients. Evaluation of serum Lp [a] and Apo-B levels should be considered a new risk factor and of prognostic value for occurrence of vascular complications in type II diabetic patients. More population-based prospective studies are needed to answer the question definitively of whether Lp [a] and Apo-B leuels are more predictive of CAD and PVD in type II diabetic individuals than the traditional lipid parameters

Fluoroscopy guided chemical lumbar sympathectomy for lower limb ischaemic ulcers.

The purpose of this study was to assess the effectiveness of chemical lumbar sympathectomy in relieving pain and healing ischaemic ulcers in patients with peripheral vascular diseases. Thirty-one consecutive patients with ischaemic/ gangrenous lower limb ulcers, referred to the BPKIHS, Pain Clinic were observed prospectively after chemical lumbar sympathectomy using modified Reid Technique with 3 ml of 70% alcohol each at L2 and L3 level under fluoroscopic guidance. Pain relief and ulcer healing were noted in the follow up. Moreover, patients' abilities to resume at least part of their day to day work were also noted at three months follow up. Of the total 31 patients, 16 had Buerger's disease and the remaining 15 had non-Buerger's ischaemic ulcers of which 7 were diabetic. There was significant decrease in the pain score from mean+/-SD of 8.3+/-0.9 (pre-block) to 4.2+/-2.5 (post-block after 3 days) in zero to 10 Numerical Analogue Scale (NAS). By 3 months, 6 patients declined for follow up; 19(76%) of the remaining 25 patients reported pain relief, 18(72%) reported healing or decrease in the size of ulcers and 11(44%) were able to resume at least part of their usual work. Minor complications occurred in 5 patients and amputation was needed in 6 patients. Fluoroscopy- guided chemical lumbar sympathectomy is feasible, safe and effective in relieving pain and promoting ulcer healing in patients with ischaemic lower limb ulcers due both to Buerger's disease and non-Buerger's peripheral vascular diseases.

Análise temporal dos resultados imediatos com a aplicação da punção transradial na intervenção coronária percutânea / Percutaneous coronary intervention: temporal analysis of immediate results using the

Fundamentos: A via de acesso transradial é uma técnica segura e eficaz para a realização de intervenções coronárias percutâneas, com baixos índices de complicações, proporcionando conforto e praticidade ao paciente. Objetivo: Efetivamos análise comparativa dos perfis clínico e angiográfico e dos resultados no período de 2000 a 2004, nos pacientes submetidos a ICP por meio da punção transradial. Método: Avaliamos os resultados intra-hospitalares de 472 intervenções coronárias percutâneas realizadas através do acesso percutâneo radial, nos últimos cinco anos, em nossa instituição. Resultados: Obtivemos sucesso angiográfico em 98,2% dos casos tratados pela via radial. Houve aumento progressivo e gradual da utilização da via de acesso radial, com 29,1% de casos tratados em 2000, chegando a 72,6% de casos tratados em 2004 (aumento de 2,5 vezes, p<0,001) e diminuição na mesma proporção dos casos tratados através da viade acesso femoral. Conclusão: A via de acesso radial é segura e eficaz, com altos índices de sucesso. Contudo, exige longa curva de aprendizado.

Background: The transradial artery approach is a safe, effective technique for percutaneous coronary interventions. Complication rate is low, and patients enjoy comfort and convenience. Objective: A comparative analysis of clinical and angiographic profiles, as well as results shown by patients submitted to PCI through transradial approach in the 2000-2004 period. Method: Immediate in-hospital results of 472 PCI were evaluated using the radial artery approach in the last five years at the same catheterization laboratory site. Results: Angiographic success was obtained in 98.2%of patients treated though radial approach. There was a progressive, gradual increase in the use of this artery, with 29.1% of all cases treated in 2000, and 72.6% of cases treated in 2004 (2.5-fold increase) with equivalent decrease of cases through femoral approach. Conclusion: The transradial access is safe and effective, with high success rates.However, it demands a long learning curve.

Performance of patients with intermittent claudication undergoing physical training, with or without an aggravation of arterial disease: retrospective cohort study / Desempenho de pacientes com claudicação intermitente submetidos ao treinamento físico em resposta ao agravamento da doença arterial: estudo retrospectivo de coorte

PURPOSE: This was a retrospective cohort study aiming to investigate the clinical outcome of patients with intermittent claudication undergoing physical training in whom there was an aggravation of the arterial disease. METHOD: Three hundred and sixty-four patients with claudication who presented with femoropopliteal or tibioperoneal obstructions in at least 1 of the lower limbs and who did not have aortic or bilateral iliac obstructions were included. Forty patients developed new stenoses in previously spared arterial segments (confirmed by duplex scanning), which were proximal to preexisting lesions, and formed the progression group, in contrast to the stable group of patients (n = 324) who did not exhibit this worsening of the disease. Follow-up was 276 and 277 days for stable and progression groups, respectively. All patients underwent an unsupervised program of submaximal walking 4 days a week. Changes in maximal walking distance at a progressive treadmill test were appraised during follow-up, with special interest directed to the periods between admission, diagnosis of arterial worsening, and the end of follow-up. RESULTS: Performance was not significantly different between groups during the entire follow-up period. Furthermore, patients with claudication who evolved with progression of their arteriopathy did not present a reduction of their maximal walking distance in response to the development of new arterial lesions at any time during their follow-up. CONCLUSION: Worsening of the peripheral arterial disease in patients with claudication undergoing physical training, manifested as de novo arterial occlusion in proximal and previously spared segments, does not imply in an impairment of their claudication distance.

OBJETIVO: Estudo retrospectivo de coorte para investigar o desfecho clínico de pacientes com claudicação intermitente submetidos a treinamento físico nos quais houve um agravamento da arteriopatia. MÉTODO: Trezentos e sessenta e quatro pacientes com claudicação que apresentavam obstruções fêmoro-poplíteas ou tíbio-peroneiras em ao menos um dos membros inferiores e que não tinham obstrução de aorta ou de ambas artérias ilíacas foram incluídos. Quarenta pacientes desenvolveram novas estenoses em segmentos arteriais previamente poupados (confirmadas por duplex scan), que eram proximais às lesões pré-existentes, e constituiram o grupo progressivo, em contraste com o grupo estável, de pacientes que não apresentou essa piora da doença. O tempo de seguimento foi de 276 e 277 dias para os grupos estável e progressivo, respectivamente. Todos os pacientes passaram por um programa não supervisionado de caminhadas submáximas 4 vezes por semana. Alterações na distância máxima de claudicação num teste de esteira com carga progressiva foram avaliadas durante o seguimento, com interesse especial nos períodos entre a admissão e o diagnóstico da progressão da arteriopatia e o final do acompanhamento. RESULTADOS: A performance não foi significantemente diferente entre ambos grupos, considerando todo o período de seguimento. Ademais, os claudicantes que evoluíram com progressão da arteriopatia não apresentaram, em nenhum momento de seu seguimento, qualquer redução da distância máxima de caminhada em resposta ao desenvolvimento de novas lesões arteriais. CONCLUSÃO: A piora da doença arterial periférica em claudicantes submetidos ao treinamento físico, manifestada por novas oclusões em segmentos arteriais proximais previamente poupados, não implica necessariamente numa piora da distância de claudicação.

review of the evaluation and management of peripheral vascular disease

Peripheral vascular disease [PVD] is a prevalent and leading public health problem. It is defined as partial or complete occlusion of one or more arteries, usually of the pelvis or lower limbs, caused by atherosclerosis. This condition is manifested by symptoms of compromised blood flow with exercise or, in severe cases, at rest. Patients with compromised blood flow to the extremities most commonly present with pain [claudication] of a muscle group. PVD is associated with increased cardiovascular mortality and morbidity. Unfortunately, it is often under-diagnosed and under-treated. Ankle-brachial index [ABI] is an inexpensive and reliable test for the screening of peripheral arterial disease. Aggressive control of risk factors, exercise rehabilitation and pharmacological interventions are highly effective in improving the symptoms of intermittent claudication and in reducing cardiovascular events

Expresión y efecto del gen de VEGF165 humano en músculo esquelético isquémico de conejos. ¿Necesidad de administración repetitiva para el tratamiento de la enfermedad vascular periféica? / Expression and effects after VEGF165 gene transfer: is it necessary the reiterative administration for the treatment of peripheral vascular disease?

Peripheral vascular disease is a disorder fifficult to treat. Due to the lack of an effective pharmacological therapy, the ischemia of an effective pharmacological therapy, the ischemia of the lower limbs pursues a relentless course, ending many times in the amputation...The authors present in this study a 6 years experience with this management, and recently the effects of an experimental model of peripheral vascular disease in rabbits is evaluated. The results obtained in this study are important because they could attribute to he trnasitority of the genetic expression the contradictory results founded in clinical assays of peripheral vascular disease

Vascular endothelial growth factor-induced angiogenic gene therapy in patients with peripheral artery disease

This phase 1 clinical trial tested the safety of intramuscular gene transfer by using naked plasmid DNA encoding the gene for VEGF, and analyzed the potential therapeutic benefits in patients with severe peripheral arterial disease (PAD). This study was an open-labeled, dose- escalating, single-center trial on nine male patients with severe debilitating PAD who had not responded to conventional therapy. Seven had Buerger's disease and two had arteriosclerosis obliterans. Plasmid DNA (pCK) containing human VEGF165 was given by eight intramuscular injections in and around the area in need of new blood vessels. The study evaluated three escalating total doses (2, 4, and 8 mg of pCK- VEGF165), with half of each total dose given four weeks apart. The follow-up duration was nine months. The gene injections were well tolerated without significant side effects or laboratory abnormalities related to gene transfer. Three patients showed transient edema in their extremities. Ischemic pain of the affected limb was relieved or improved markedly in six of seven patients. Ischemic ulcers healed or improved in four of six patients. The mean ankle-brachial index (ABI) improved significantly. Six of nine patients showed an increase in collateral vessels around the injection sites demonstrated by digital subtraction angiography. However, there was no relationship between the degree of ABI improvement and the dose given. Mean plasma levels of VEGF did not increase significantly. In conclusion, intramuscular injections of pCK- VEGF165 can be performed safely to induce therapeutic angiogenesis in patients with severe PAD.

Angiogênese terapêutica obtida pela transferência gênica do 'VEGF IND 121' em tecido muscular esquelético: impacto sobre a perfusão tecidual após a indução de isquemia / Therapeutic angiogenesis achieved by gene transfer of vascular endothelial growth factor ('VEGF IND 121') in skeletal muscle: impact on tissue perfusion after the induction of ischemia

Testou-se a hipótese de que a injeção intramuscular de um vetor carreador do gene VEGF121 (AdCMV.VEGF121) estimula a angiogênese em músculo esquelético não-isquêmico e melhora a perfusão tecidual após a indução de isquemia. Coelhos e ratos receberam injeções de AdCMV.VEGF121, AdCMV.Null, ou salina, anteriormente à remoção da artéria femoral. No local da injeção de VEGF121, observou-se aumento de 96 por cento e 29 por cento em arteríolas e capilares, respectivamente. No grupo VEGF121, maior fluxo sangüíneo regional no músculo gastrocnêmio, maior número de vasos colaterais e melhora da reserva bioenergética muscular foram observados. Assim, a administração IM de AdCMV.VEGF121 estimula a angiogênese em tecido muscular esquelético normoperfundido e os vasos neoformados preservam a perfusão tecidual após a indução de isquemia.We tested the hypothesis that adenovirus-mediated intramuscular gene transfer of VEGF121 (AdCMV.VEGF121) could stimulate neovascularization in nonischemic skeletal muscle and improves tissue perfusion after the induction of ischemia. Rabbits and rats received injections of AdCMV.VEGF121, AdCMV.Null, or saline, before femoral artery removal. We found 96 per cent and 29 per cent increases in arterioles and capillaries, respectively. In the VEGF121 group, we also found improved blood flow to the ischemic gastrocnemius muscle, more collateral vessels, and improvement of the muscular bioenergetic reserve. Thus, IM administration of AdCMV.VEGF121 stimulates angiogenesis in normoperfused skeletal muscles, and the newly formed vessels preserve tissue perfusion after the induction of ischemia...