Stent-induced flow disturbances in the ipsilateral external carotid artery following internal carotid artery stenting: a temporary cause of jaw claudication.

BACKGROUND: We hypothesize that stenting of the internal carotid artery can immediately impede blood flow to the external carotid artery by either plaque shift or stent coverage of the ostium, and thereby cause ischemic symptoms like ipsilateral jaw claudication. METHODS: Thirty-three patients with high-grade asymptomatic stenosis of the internal carotid artery who underwent endovascular treatment were examined by ultrasound of the external carotid artery and performed an exercise test by chewing chewing gum synchronously to an electronic metronome for 3 min. Tests were performed before, the day after, and 1 week after the stenting procedure. Claudication time was defined as the timespan until occurrence of pain of the masseter muscle and/or chewing dyssynchrony to the metronome for more than 15 s. Ten patients with an isolated, atherosclerotic stenosis of the external carotid artery served as controls. RESULTS: A significantly reduced claudication time (in seconds) was recorded in patients who underwent carotid artery stenting compared to baseline values; median 89 (interquartile range, IQR, 57 to 124) vs. median 180 (IQR 153 to 180; p < 0.001). By categorization of the flow velocity at the external carotid artery into faster or slower as 200 cm/sec, the effect was even accentuated. Stenting values showed improvement 1 week after but did not return to baseline levels. No respective changes were found in controls. CONCLUSION: Stenting of the internal carotid artery lead to ipsilateral flow deterioration at the external carotid artery resulting in temporary jaw claudication. This impairment attenuated over the time and was significantly reduced after 1 week.

Combined Effects of Inflammatory Status and Carotid Atherosclerosis: A 12-Year Follow-Up Study.

BACKGROUND AND PURPOSE: Inflammatory responses play a key role in atherogenesis. The aim of this study was to assess the prognostic value of hsCRP (high-sensitivity C-reactive protein) and to evaluate whether degree of carotid stenosis and serum levels of hsCRP jointly predict long-term mortality in asymptomatic patients with carotid atherosclerosis. METHODS: One thousand sixty-five patients with neurological asymptomatic carotid atherosclerosis as evaluated by duplex sonography were prospectively followed for cause-specific mortality. RESULTS: During a median of 11.81 years, a total of 549 deaths, including 362 cardiovascular deaths, were recorded. The risk of all-cause and cardiovascular mortality significantly increased in patients with elevated serum levels of hsCRP (the adjusted hazard ratio for cardiovascular mortality per increase of 1 mg/dL of hsCRP levels was 1.47; P<0.001). Patients with a high degree of carotid stenosis and increased hsCRP levels were particularly at risk of adverse outcome. Patients with carotid narrowing over 50% and hsCRP levels >0.29 mg/dL (=median) had nearly twice as high a risk of cardiovascular mortality compared with patients with carotid stenosis of <50% and hsCRP levels <0.29 mg/dL (adjusted hazard ratio 1.89; P<0.001). Improvement in risk stratification with combined assessment of carotid stenosis and hsCRP was confirmed by an improvement of the continuous net reclassification improvement with 18% for all-cause mortality and 15% for cardiovascular mortality compared with the degree of carotid stenosis alone (P<0.01). CONCLUSIONS: Measurement of hsCRP in combination with ultrasound investigations of the carotid arteries at a single time point provides additional prognostic information for patients with asymptomatic carotid atherosclerosis.

Vascular puncture site complications - diagnosis, therapy, and prognosis.

The numbers of endovascular procedures have been noted to substantially increase over the past two decades. Besides all the technical advances and the increasing skills of more and more trained interventionists, the vascular access site still offers the possibilities and carries the risk of access site complications, which have not been changed dramatically over the past years. Guidelines on the vascular puncture procedure itself are lacking. Complications at different vascular access sites presentclinically different, require different diagnostic work up and therapy. The aim of the following review is to systematically list the most likely vascular access site complications their diagnosis and if necessary the proper treatment.

Percutaneous instillation of physiological saline solution for the treatment of femoral pseudoaneuryms.

OBJECTIVE: To investigate the efficacy of para-aneurysmal saline injection for closure of postcatheterization pseudo-aneurysm (PA) at the vascular access site. METHODS: Fifty-one consecutive patients with postcatheterization PA at the vascular access site were included to undergo percutaneous para-aneurysmal saline injection. In case of technical failure the day after, PA were treated by bovine thrombin injection. Anatomical properties of the PA were recorded as were details to injection. RESULTS: Initially all patients exhibited success which was reduced to 43 % at day one. A saline volume of median 7 ml (interquartile range 6-8 ml) has been injected. The amount of injected saline was not different in patients with and without treatment success at day one (P = 0.6). Several anatomical properties of the PA exhibited marked differences in patients with or without success. The length (10.3 mm (7.8-12.0) vs. 12.5 mm (10.3-15.0); P = 0.009) and the angulation (110° (100-118) vs. 140° (129-146); P < 0.001) of the fistula/vessel axis was statistically different between groups. The peak systolic velocity failed to show significance with a tendency to higher values in the ineffective study group (P = 0.07). No peripheral complications occurred. CONCLUSION: Para-aneurysmal saline injection may be a therapeutic alternative to percutaneous thrombin injection in patients exhibiting favorable anatomical properties.

The impact of selectins on mortality in stable carotid atherosclerosis.

Cellular adhesion molecules also known as selectins promote recruitment of inflammatory cells into the arterial wall where they interact with lipid particles leading subsequently to plaque formation. The intercellular adhesion molecule-1 (ICAM-1), the vascular cell adhesion molecule-1 (VCAM-1) and the endothelial-leukocyte adhesion molecule 1 (ELAM-1) also known as E-selectin mediate the attachment of leukocytes and have been implicated in the destabilisation of atherosclerotic plaques. Therefore, we hypothesised that plasma selectin levels are associated with adverse clinical outcome. We prospectively studied 855 patients with sonographically confirmed carotid atherosclerosis. During a median follow-up of 6.2 years, corresponding to 5,551 overall person-years, 275 patients (26 %) died. We detected a significant association between cardiovascular mortality and ICAM-1 (adjusted hazard ratio [HR]: 3.43, 95 % confidence interval [CI] 2.00-5.88, p< 0.001) as well as VCAM-1 (adjusted HR: 2.51, 95 %CI 1.45-4.34, p=0.001) when comparing the fourth with the first quartile. Comparable results were obtained for all-cause mortality. In contrast, we could not detect a significant association between E-selectin and all-cause or cardiovascular mortality. We identified the selectins ICAM-1 and VCAM-1 as strong and independent predictors of all-cause and cardiovascular mortality in patients with stable carotid atherosclerosis. These molecules are elevated in states of endothelial activation and might assist to monitor anti-atherosclerotic therapy and select those patients with carotid atherosclerosis, who are at higher risk for cardiovascular events.

Relationship of age and body mass index to skin temperature and skin perfusion in primary Raynaud's phenomenon.

OBJECTIVE: To assess the relationship of age and body mass index (BMI) to skin temperature and perfusion in patients with primary Raynaud's phenomenon (RP) compared with controls. METHODS: Patients with RP as well as age- and sex-matched controls underwent external cold provocation by exposure to 20 °C water for 1 minute. Before and after cold provocation, skin temperature and skin perfusion were measured. RESULTS: Twenty-six patients with RP (20 women and 6 men; median age 41.9 years) and 22 controls (17 women and 5 men; median age 42.9 years) were studied. In RP patients, cold exposure led to a median change in skin temperature of -7% (interquartile range [IQR] -13.1, -4.1) and to a median change in skin perfusion of -26.4% (IQR -36.2, 2.9). In controls, skin temperature changed by -15.7% (IQR -18.3, -11.6) and skin perfusion by -33% (IQR -53.3, -1.1) upon cold exposure. In patients with RP, age and BMI were related to skin temperature (for age, r = 0.683, P < 0.0001; for BMI r = 0.657, P < 0.0001) and skin perfusion (for age, r = 0.595, P = 0.002; for BMI, r = 0.653, P < 0.0001), while no association was found in controls. The cold-induced decrease in skin temperature was inversely related to age (r = -0.518, P = 0.003) and BMI (r = -0.662, P < 0.0001) in patients with RP; correlations were not observed in controls. The cold-induced change in skin perfusion was not related to age or BMI in either group. CONCLUSION: The cold-induced decrease in skin temperature is related to age and BMI in patients with RP but not in controls. Further studies are needed to clarify the pathophysiology of digital ischemia in primary RP.

Renal function and long-term mortality in patients with asymptomatic carotid atherosclerosis.

Renal dysfunction is a risk factor for mortality in patients with atherosclerosis. Estimated glomerular filtration rate (eGFR), cystatin C (CysC) and beta-2-microglobulin (B2M) are measures of renal function. It remains unclear, which of these parameters is the strongest predictor of outcome in patients with atherosclerosis. All-cause and cardiovascular mortality were prospectively investigated in 1,065 consecutive patients with asymptomatic carotid atherosclerosis. During a median follow-up of 6.3 years 275 patients died (25.8%), including 182 (66.2%) from cardiovascular causes. Estimated GFR, CysC and B2M were all significantly and independently associated with mortality. Inclusion of the renal parameters CysC and B2M but not of eGFR into a model with established cardiovascular risk factors improved the C-statistics significantly (p=0.0035 and 0.036, respectively; p=0.182 for eGFR). The net reclassification improvement (NRI) was 32.4% (p<0.0001) for CysC, 29% (p<0.0001) for B2M, and 16.5% (p=0.019) for eGFR. The integrated discrimination improvement (IDI) was 0.014 (p=0.0009) for CysC and 0.011 (p=0.005) for B2M while it was not significant for eGFR. Results were consistent for various subgroups with different extent of atherosclerosis. In summary, CysC and B2M were found to be independent predictors for mortality and had superior predictive value compared to eGFR in patients with asymptomatic carotid atherosclerosis. The clinical importance of these findings has to be validated in larger studies with a community-based approach.

[Perspectives of mobile communication in the management of diabetics]. / Diabetes-Management über Mobilfunknetze: Perspektiven.

Sufficient control of blood glucose levels has been demonstrated to be associated with improved long-term outcome in patients with diabetes. Recent advances in interface technology allow transfer of measurement data to mobile devices, which enables control, multiple access, and storage of these data and virtually links patients and care-giving physicians. The possibility of alerting predefined addressee in case of measurements below or above certain limits offers some sort of security that cannot be obtained by simply penning a single value to a scratchpad. Therefore, treating physicians are able to follow the therapeutic course in an easy and finally time-independent manner. Furthermore, physical contact is not necessary, which may be favorable especially for elderly, sometimes immobile patients.

The prognostic impact of soluble apoptosis-stimulating fragment on mortality in patients with carotid atherosclerosis.

BACKGROUND AND PURPOSE: Markers of apoptosis are associated with cardiovascular disease. The soluble apoptosis-stimulating fragment (sFAS) was found to be a predictor for outcome in patients with heart failure, but its importance in patients with atherosclerotic disease has not been fully understood as yet. The aim of the present study was to investigate the impact of sFAS on all-cause and cardiovascular mortality in patients with atherosclerosis in the carotid arteries. METHODS: We studied 981 of 1286 consecutive patients with neurological asymptomatic carotid atherosclerosis as evaluated by duplex Doppler sonography. Patients were prospectively followed for long-term all-cause and cardiovascular mortality. RESULTS: During a median follow-up of 6.2 years (interquartile range, 5.9 to 6.6 years), a total of 250 deaths (25.5%), including 165 (66%) cardiovascular deaths, were recorded. The risk for all-cause and for cardiovascular mortality, respectively, increased significantly with sFAS concentrations (P<0.001). The hazard ratio for all-cause death was elevated by 2.3-fold (P<0.001) and for cardiovascular death by 2.4-fold (P<0.001) in patients within the highest quintile of sFAS compared with patients within the lowest quintile, respectively. Results remained significant after adjustment for potential confounders and established cardiovascular risk factors, including high-sensitivity C-reactive protein. Patients with high sFAS but low high-sensitivity C-reactive protein had a comparable survival rate with those with elevated high-sensitivity C-reactive protein only (P=0.50). CONCLUSIONS: Markers of apoptosis, as measured by sFAS, were found to be independent risk predictors for death in patients with atherosclerotic disease in the carotid arteries.

The impact of dental disease on mortality in patients with asymptomatic carotid atherosclerosis.

BACKGROUND: Dental status and oral hygiene are associated with progression of atherosclerosis in patients with carotid stenosis. It remains unclear whether dental disease is a risk factor for mortality in these patients. We evaluated the bearing of dental disease on mortality among patients with asymptomatic carotid atherosclerosis. METHODS: Three World Health Organization-validated indices in 411 patients with asymptomatic carotid atherosclerosis were evaluated, measuring DMFT (decayed, missing, filled teeth) for dental status, CPITN (community periodontal index for treatment needs) for periodontal status and SLI (Silness-Löe Index) for oral hygiene respectively. Patients were prospectively followed for median 6.2 years (IQR 5.8 to 6.6 years) for all-cause mortality. RESULTS: During follow-up, 107 (26%) deaths occurred (74 cardiovascular causes). DMFT and SLI, but not CPITN, showed a significant and gradual association with mortality. For continuous variables, the adjusted hazard ratios (HR) for death were 1.06 (95% CI 1.0 to 1.12; p = 0.04) for DMFT, and 1.43 (95% CI, 1.01 to 2.03; p = 0.04) for SLI respectively. Edentulousness was a significant risk factor for death (adjusted HR 1.99, 95% CI, 1.18 to 3.02; p = 0.008). CONCLUSION: Dental status and oral hygiene were associated with mortality in patients with carotid atherosclerosis regardless of conventional cardiovascular risk factors.

Beta 2 microglobulin and the risk for cardiovascular events in patients with asymptomatic carotid atherosclerosis.

BACKGROUND AND PURPOSE: Atherosclerosis is a chronic inflammatory disease. Ongoing inflammation is associated with elevated levels of beta 2 microglobulin (B2M). We investigated B2M levels in a large cohort of patients with carotid atherosclerosis for the occurrence of major adverse cardiovascular events. METHODS: One thousand five of 1286 consecutive, neurologically asymptomatic patients with carotid atherosclerosis were followed for a median of 3 years (interquartile range, 2.5 to 3.5) for the occurrence of major adverse cardiovascular events, a composite of myocardial infarction, percutaneous coronary intervention, coronary bypass graft, stroke, and death. RESULTS: We recorded 359 major cardiovascular events in 271 (27%) patients. B2M was significantly associated with the occurrence of major adverse cardiovascular events. With increasing quartiles of B2M, the adjusted hazard ratios were 1.19 (95% CI, 0.81 to 1.73), 1.51 (95% CI, 1.05 to 2.18), and 1.88 (95% CI, 1.26 to 2.79) compared with the lowest quartile, respectively (P<0.001). Adjusted hazard ratios for the occurrence of death, myocardial infarction, and stroke for increasing quartiles of B2M were 1.25 (95% CI, 0.92 to 1.70), 1.52 (95% CI, 1.12 to 2.06), and 1.62 (95% CI, 1.16 to 2.67) compared with the lowest quartile, respectively (P<0.001). Through statistical estimation of improvement in risk stratification, addition of B2M to baseline risk factors improved the risk stratification for major cardiovascular events, at least as much as high-sensitivity C-reactive protein or even better. CONCLUSIONS: B2M was independently and significantly associated with adverse cardiovascular outcome in patients with prevalent asymptomatic carotid atherosclerosis.

Prognostic value of plasma d-dimer levels in patients with glioblastoma multiforme - Results from a pilot study.

Glioblastoma multiforme (GBM), the most common primary tumor of the central nervous system, is associated with a state of hypercoagulability. We hypothesized that tumor activity is displayed by elevated d-dimer plasma levels and that d-dimer might be used as a predictor of survival in patients with glioblastoma multiforme. We studied effects on clinical outcomes of d-dimer levels obtained two to three weeks following histologic confirmation of the diagnosis of GBM at surgery or needle biopsy, but prior to chemotherapy or radiation therapy, in 23 patients. During a median follow-up of 7.3 months (interquartile range 3.5 to 22 months), we observed a total of 21 deaths (91.3%). Elevated d-dimer levels were significantly associated with mortality compared to normal values (log rank p = 0.002). The adjusted hazard ratio for death in patients with elevated d-dimer levels was 10.8 (95% confidence interval, 1.3 to 93.1; p = 0.03), compared to controls. Similar effect sizes were revealed when analyzing the association between progression-free survival and d-dimer levels (log rank p = 0.002). Additionally, patients with elevated d-dimer levels were more likely to suffer from venous thromboembolism compared to patients with normal values (log rank p = 0.025). Our data support the assumption that d-dimer levels are related to adverse outcome in patients with GBM. However, our results need to be confirmed by a large, prospective cohort study.

Auricular electroacupuncture reduces frequency and severity of Raynaud attacks.

BACKGROUND: Acupuncture has been shown to influence skin perfusion and the subjective cold perception threshold. Therefore, we hypothesized that auricular electroacupuncture (EA) might reduce symptoms in primary Raynaud's phenomenon (PRP). METHODS: Twenty-six patients with PRP received 6 cycles of auricular EA. After 3, 6 and 24 weeks attack frequency and severity were reevaluated using standardized questionnaires and a visual analogue scale (VAS). Skin temperature was assessed by infrared thermography and laser Doppler perfusion imaging was used to determine skin perfusion. RESULTS: Compared to baseline we found a significant reduction of attack frequency after 3 (p = 0.001) and 6 weeks (p < 0.001) of auricular EA. This improvement sustained following cessation of EA, after 24 weeks (p < 0.001). Furthermore, attack associated pain was reduced after 3 (p = 0.003), 6 (p = 0.003) and 24 weeks (p = 0.001) of treatment, while skin temperature and skin perfusion did not change significantly throughout the study period. CONCLUSIONS: Auricular EA reduces symptoms by means of frequency and severity of attacks in PRP but has no influence on skin perfusion and skin temperature.

Polymorphism of the palladin gene and cardiovascular outcome in patients with atherosclerosis.

BACKGROUND: A single-nucleotide polymorphism (SNP) in the palladin gene (PALLD, rs7439293) has recently been reported to be associated with coronary heart disease (CHD) in two case-control studies as well as in a large population-based cohort (Atherosclerosis Risk in Communities study, ARIC). Its clinical relevance, however, has not been evaluated prospectively. We investigated whether the risk allele (A) of PALLD rs7439293 (G>A) is associated with the occurrence of future major cardiovascular events (MACE) in a cohort of patients with prevalent carotid atherosclerosis. MATERIALS AND METHODS: A total of 1283 consecutive patients with neurologically asymptomatic carotid atherosclerosis were included in the study and prospectively followed for a median of 3·5 years (interquartile range 3-4 years). We analysed whether the risk allele is associated with progression of carotid atherosclerosis after a 6-9-month period as measured by duplex Doppler sonography. Patients were then followed for the occurrence of a first MACE, a composite of myocardial infarction, stroke, coronary revascularization and death. RESULTS: After a median of 7·5 months (interquartile range 6-9 months), progression of carotid stenosis was observed in 103 (8·1%) patients. Cardiovascular events occurred in 337 (30%) patients after a median follow-up of 3·5 years. The risk allele of PALLD was neither associated with progressive carotid atherosclerosis (P = 0·21) nor with MACE (P = 0·58). Adjusted hazard ratios for a first MACE in heterozygous and homozygous carriers were 0·83 (95% CI 0·58-1·18) and 0·94 (95% CI 0·65-1·35) compared to wild type, respectively. CONCLUSIONS: The A-allele of PALLD rs7439293 was not associated with progressive carotid atherosclerosis as measured by duplex Doppler sonography nor did it represent a risk factor for adverse cardiovascular outcome among patients with prevalent carotid atherosclerosis.

D-dimer testing in the diagnosis of transfemoral pseudoaneurysm after percutaneous transluminal procedures.

OBJECTIVE: Pseudoaneurysms are characterized by extravascular circulation and therefore may lead to an activation of the coagulation cascade. We investigated d-dimer levels in patients with and without postcatheterization femoral pseudoaneurysms and hypothesized that d-dimer levels correlate with the presence of pseudoaneurysms at the vascular access site. METHODS: Patients with clinical suspected groin pseudoaneurysms after transluminal procedures were eligible. We compared prospectively-collected laboratory values of quantitative d-dimer testing in patients with and without pseudoaneurysms as assessed by color-coded duplex sonography. Furthermore, we measured the peak systolic velocity at the arterial fistula of each pseudoaneurysm. RESULTS: In 48 (40%) of 120 consecutive patients, a pseudoaneurysm was found. The level of d-dimer values was significantly higher in patients with postcatheterization femoral pseudoaneurysms compared with controls (1.9 microg/mL [interquartile range (IQR), 1.34-2.78 microg/mL] vs 0.8 microg/mL [IQR, 0.53-1.14 microg/mL]; P < .001). Values of d-dimer below 0.67 microg/mL have been calculated with a sensitivity of 94% (87%-100%), a specificity of 38% (27%-50%), a positive predictive value of 50% (40%-60%), a negative predictive value of 90% (82%-99%), and a likelihood ratio of 1.52 (1.25-1.85) with regard to the presence of pseudoaneurysms. We also found a significant correlation of the peak systolic velocity at the arterial fistula and increasing d-dimer levels (r = 0.98, P < .0001). CONCLUSION: We found a significantly higher level of d-dimer values in patients with femoral pseudoaneurysms at the vascular access site. Therefore, d-dimer levels could be a potential serological marker in the diagnosis of pseudoaneurysms. A confirmation is warranted in a larger patient sample.

Correlation of infrared thermography and skin perfusion in Raynaud patients and in healthy controls.

BACKGROUND: We aimed to investigate the correlation of infrared thermography (IT) with laser Doppler perfusion imager (LDPI) among patients with primary Raynaud's phenomenon and healthy controls. METHODS: Forty-seven individuals were included: we examined 25 patients with primary Raynaud's phenomenon and 22 age and gender matched healthy controls. IT of the volar surface of the subjects' left hands was performed to record skin temperature while skin perfusion of the same area was determined using LDPI. All measurements were obtained at room temperature (baseline measurements) and following standardized cold provocation. RESULTS: Good correlation of baseline measurements was found between IT and LDPI in primary Raynaud patients and healthy controls (r=0.868, p<0.0001 vs. r=0.790, p<0.0001). Following cold challenge, correlation was weaker in both groups (r=0.742 vs. r=0.766, p<0.0001). Correlation after cold provocation was statistically significant among patients with primary Raynaud's phenomenon in contrast to controls (Chi Quadrat, p=0.023 vs. p=0.306). CONCLUSION: A significant correlation was found between IT and LDPI in primary Raynaud patients and in healthy controls (r=0.868 and r=0.742, both p<0.0001). Following cold provocation, correlation decreases in both groups. Thus, at room temperature IT might substitute for skin perfusion measured by LDPI.

Cystatin C and the risk for cardiovascular events in patients with asymptomatic carotid atherosclerosis.

BACKGROUND AND PURPOSE: Renal dysfunction is a risk factor for cardiovascular events in patients with atherosclerosis. Unlike serum creatinine or estimated glomerular filtration rate, cystatin C reflects renal dysfunction independent of factors such as sex, weight, and race. We investigated whether baseline serum levels of cystatin C predict major cardiovascular events in patients with asymptomatic carotid atherosclerosis and compared the predictive value of cystatin C to these established markers of renal function. METHODS: We prospectively studied 1004 of 1286 consecutive patients with carotid ultrasound scanning. Patients were followed for the occurrence of major cardiovascular events, a composite of myocardial infarction, percutaneous coronary intervention, coronary bypass graft, stroke, and death. RESULTS: During a median of 3 years of follow-up, we recorded 346 major cardiovascular events in 311 patients. The risk for a first major cardiovascular event increased significantly with increasing quintiles of cystatin C; hazard ratios ranged from 1.18 to 1.94 for the highest versus the lowest quintile (P<0.001 for trend). Creatinine levels showed no significant association with major cardiovascular events, and for glomerular filtration rate, only the lowest quintile was moderately associated with adverse cardiovascular outcome. CONCLUSIONS: Cystatin C was significantly and gradually associated with future cardiovascular events in patients with carotid atherosclerosis. In contrast, neither serum creatinine nor estimated glomerular filtration rate were significant predictors of adverse cardiovascular outcomes.

Balloon angioplasty versus stenting with nitinol stents in intermediate length superficial femoral artery lesions.

BACKGROUND: Recent randomized trials investigating stent implantation compared with balloon angioplasty for treatment of superficial femoral artery (SFA) disease have given divergent results in short (mean 5 cm) and intermediate (mean 10 cm) lesions. We reinvestigated whether primary nitinol stenting is associated with a morphologic and clinical benefit when compared with percutaneous transluminal angioplasty with optional stenting (PTA) in intermediate-length lesions. METHODS: We randomly assigned 73 patients with severe claudication or chronic limb ischemia and average 8 cm long (range 3-20 cm) SFA stenosis or occlusion to primary stent implantation (n = 34) or PTA (n = 39). Restenosis >50% and clinical outcome were assessed at 3, 6, and 12 months postintervention. RESULTS: Average length of the treated segments was 98 + or - 54 mm and 71 + or - 43 mm in the stent and PTA groups (P = 0.011), respectively. In the PTA group, secondary stenting was performed in 10 of 39 patients (26%) due to a suboptimal result after balloon dilation. Restenosis rates in the stent and PTA groups were 21.9% versus 55.6% (P = 0.005) at 6 months by CT-angiography, and 2.9% versus 18.9% (P = 0.033), 18.2% versus 50.0% (P = 0.006), and 34.4% versus 61.1% (P = 0.028) at 3, 6, and 12 months by sonography, respectively. Clinically, patients in the stent group reported a significantly higher maximum walking capacity compared with the PTA group at 6 and 12 months. CONCLUSION: In this randomized multicenter trial, primary stenting with a self-expanding nitinol stent for treatment of intermediate length SFA disease resulted morphologically and clinically superior midterm results compared with balloon angioplasty with optional secondary stenting.

Inflammation and adverse cardiovascular outcome in patients with renal artery stenosis and peripheral artery disease.

OBJECTIVES: We hypothesized that high sensitivity C-reactive protein (hs-CRP) and the presence of renal artery stenosis (RAS) might conjointly predict future major adverse cardiovascular events (MACE) in patients with peripheral artery disease (PAD). BACKGROUND: Clinical outcome in PAD is determined by the extent of atherosclerosis affecting additional vascular beds and the activity of the atherosclerotic process reflected by inflammatory serum markers. Data on the predictive value of hs-CRP on outcome in PAD patients with RAS is limited. METHODS: We prospectively enrolled 447 PAD patients who were admitted to our institution for angioplasty. Preintervention hs-CRP was assessed and renal angiograms were obtained. Patients were then followed clinically for the occurrence of MACE for median 15.6 months. Serum creatinine was obtained in all patients at 12 months. RESULTS: Incidental RAS >or=60% at baseline was found in 68 patients (15.2%), MACE were recorded in 111 patients during follow-up. Hs-CRP was significantly associated with the occurrence of MACE (p<0.001) and with 12 months creatinine levels (p=0.005). Adjusted hazard ratios for MACE for increasing quartiles of hs-CRP as compared to the lowest quartile were 1.11 (95% CI 0.53-2.35), 1.06 (95% CI 0.50-2.26) and 2.79 (95% CI 1.47-5.28). Analyzing joint effects of hs-CRP and RAS, we observed no significant interaction. CONCLUSION: Hs-CRP predicts cardiovascular and renal outcome in PAD patients irrespective of the presence of RAS. Patients with hs-CRP levels above 0.88 mg/dL were at particularly high risk for MACE.

Decreasing incidence of critical limb ischemia after intra-aortic balloon pump counterpulsation.

The authors investigated the incidence of critical limb ischemia (CLI) in 187 patients with intra-aortic balloon pump (IABP) support during a 6-year study period and determined risk factors and long-term outcome (median 5 years) after discharge from a cardiac intensive care unit. Cardiogenic shock following acute myocardial infarction was the predominant cause of IABP support. CLI occurred in 10% of the patients after IABP implantation. Nevertheless, in light of the overall high mortality in this patient population, CLI seems not a primary concern. Furthermore, its incidence significantly decreased during recent years. Duration of IABP support was a significant predictor for CLI.