Complex Vascular Revascularization in a Young Woman with Type 1 Neurofibromatosis.

We present an uncommon case of a 16-year-old woman with type 1 neurofibromatosis and renovascular hypertension due to bilateral renal stenosis associated with asymptomatic digestive artery stenosis. Our patient was treated by several autologous bypasses to the superior mesenteric artery and the left and right renal arteries. She had no postoperative complications and good clinical and imaging outcomes at 10 years. Furthermore, there are few data on the vascular impairment of this rare disease, thus justifying its presentation.

Arteriovenous fistulas for hemodialysis: application of high-frequency US to assess vein wall morphology for cannulation readiness.

PURPOSE: To determine whether venous wall thickness and hoop (circumferential) stress, as determined with high-frequency ultrasonography (US), can predict cannulation readiness in arteriovenous fistulas (AVFs). MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained for this prospective study. To determine the US appearance of the venous wall, an AVF specimen was excised and scanned in a bath of degassed lactated Ringer solution with a 55-MHz probe. The appearance of the wall at high-frequency US was correlated with histologic findings. High-frequency (40-55-MHz) US was used to image the near-field AVF venous wall of 14 men (mean age, 59 years ± 11 [standard deviation]) and six women (mean age, 55 years ± 14) with newly created AVFs within 1 week of cannulation between January 2008 and December 2009. Measurements of the intima-media thickness (IMT) were generated by three independent observers who were blinded to outcomes. Intraclass correlation analysis was performed. Cannulation readiness was defined as no extravasation during the first dialysis treatment. RESULTS: By using high-frequency US, the IMT was defined as the sum of a thin echogenic blood-intima interface and a uniform hypoechoic media. The mean IMT of the no extravasation group (0.16 mm ± 0.03) was greater than that of the extravasation group (0.10 mm ± 0.02) (P < .001). A minimum threshold IMT of 0.13 mm (P < .001) was associated with successful cannulation. The mean hoop stress of the no extravasation group (246 kPa ± 57) was lower than that of the extravasation group (530 kPa ± 199) (P < .001). A maximum hoop stress threshold of 248 kPa was associated with successful cannulation (P = .009). CONCLUSION: Venous IMT and hoop stress assessed with high-frequency US can predict cannulation readiness in AVFs that are clinically deemed mature.

Efficacy and long-term safety of StarClose™ for hemostasis of arterial puncture sites distal to common femoral artery bifurcation after percutaneous coronary interventions.

BACKGROUND: Currently approved vascular closure devices (VCDs) are not recommended for use in arterial puncture sites distal to the common femoral artery (CFA) bifurcation. The StarClose™ vascular system (SC) is a unique VCD that does not contain intravascular components, a feature that may allow safe use in smaller vessels. OBJECTIVE: We sought to determine the efficacy and long-term safety of the SC for hemostasis of arterial punctures distal to the CFA bifurcation. METHODS: Consecutive patients with arterial puncture sites located distal to the CFA bifurcation received SC after percutaneous coronary intervention (PCI). Patients were ambulated 4-6 hours later, and the presence of vascular complications was determined clinically before hospital discharge. Clinical and Doppler ultrasound examinations were performed at 8-9 months to assess long-term safety. RESULTS: A total of 106 patients undergoing PCI were included in the study. Mean age was 66 ± 12 years and 63% were male. The arterial puncture site was located in the superficial femoral artery (SFA) in 76 (72%), the profunda femoris artery (PFA) in 22 (21%) and undetermined in 8 (7%) patients. The mean diameter of the CFA was significantly greater than the SFA or the PFA branch with the SC (6.2 ± 1.5 vs. 4.5 ± 1.0 mm for the CFA and branch with SC, respectively; p < 0.0001). Device success was achieved in 102 (96%) patients. At 24 hours, a hematoma ≥ 5 cm was reported in 13 (12%) patients. No other vascular complications occurred. At a mean follow up of 9 ± 2.5 months, there was no clinical or Doppler evidence of arterial insufficiency or vascular complications. CONCLUSION: The SC can be used for hemostasis after PCI in select cases where the arterial puncture site is located distal to the CFA bifurcation without adverse clinical outcomes.

Prospective assessment of lower-extremity peripheral arterial disease in diabetic patients using a novel automated optical device.

A new optical device based on the photoplethysmograph (PPG) method and an innovative algorithm for the assessment of lower-extremity peripheral arterial disease was investigated prospectively in patients with type II diabetes. This new functional PPG (fPPG) technique uses a cuffless functional test to assess diabetic peripheral arterial disease without operator dependency and the incompressible arteries, issues associated with ankle brachial pressure index (ABPI) measurement. Diabetic patients (n = 24; 47 legs; age, 70 +/- 3 years) were recruited from the vascular clinic, and controls (n = 15; 30 legs; age, 66 +/- 5 years) were recruited from the orthopedic outpatient clinic. All underwent resting ABPI, fPPG, and duplex angiography (DA) as "gold standard." fPPG requires the placement of an optical probe on the toe for acquisition of pulsatile arterial perfusion for a period of 30 seconds with the leg in supine and raised at 45 degrees positions. The data were analyzed, and indices were generated by an automated computer system. In those with diabetes, fPPG correlated significantly with DA (r = -.68, P < .01) and ABPI (r = -.65, P < .01). We also found a significant correlation between ABPI and DA (r = .81, P < .01). The analysis of the receiver operator curve showed that optimum sensitivity and specificity for ABPI and fPPG were 80% and 93% and 83% and 71%, respectively, against DA. This method uses changes in pulsatile arterial blood volume using a simple cuffless functional test. The fPPG investigation period was much shorter (5 minutes) with independence of operator skills, whereas ABPI took longer (10-15 minutes) and required operator experience. Although the fPPG results are promising, further improvement (eg, by incorporation of functional skin color and temperature changes) is required to improve the sensitivity and specificity of the system.

Assessment of lower extremity peripheral arterial disease using a novel automated optical device.

The resting ankle-brachial pressure index (rABPI) is used in the diagnosis of lower extremity peripheral arterial disease (PAD) in symptomatic and asymptomatic patients. This article compares the rABPI with a new optical device based on photoplethysmograph (PPG) technology with new algorithms for the assessment of PAD. Functional PPG (fPPG) is a promising noninvasive automated device using a novel cuffless functional test for assessing mild or significant PAD without the operator dependency issues associated with rABPI. This system utilizes both changes in pulsatile arterial blood volume and skin color redness in lower limbs. All subjects underwent rABPI, fPPG, and duplex angiography (DA). Significant correlation was found between fPPG and DA scores, rABPI and DA, and fPPG and rABPI. In the hands of operators with little experience, fPPG may prove to be superior to rABPI and may be useful as a simple screening tool for early detection of PAD in primary care.