Reversal of Lower-Extremity Intermittent Claudication and Rest Pain by Hydration.

BACKGROUND: Medical treatment of disabling intermittent claudication or critical limb-threatening ischemia causing rest pain often fails or has partial response. METHODS: In this pilot study, 36 patients (12 females) affected by disabling intermittent claudication or rest pain of the lower extremities were exposed to a daily 3-L water intake for up to 6 weeks. Cutaneous foot temperature, ankle/brachial index, time and distance of claudication, and pain intensity were recorded before and at the completion of the hydration period. RESULTS: Patients with a mean ± SE age of 71 ± 2 years (range, 40-86) had disabling claudication (less than 100 meters) for more than 5 months while 11% reported pain at rest. A 6-week water intake of more than 2,500 mL/24 hr was achieved in 35 of the 36 patients enrolled in the study. Increased water intake was associated with significant improvements in median ankle/brachial index (from 0.60 to 0.76; P < 0.0001) and skin temperature (first dorsal right toe, from 29.95°C to 30.0°C, P < 0.001). Time and distance to report claudication of supervised treadmill exercise improved from 1.25 to 6.25 min (P < 0.0001) and from 100 meters to 535 meters (P < 0.0001), respectively. CONCLUSIONS: This study suggests that hydration attained by daily water consumption of more than 2.5 L has a robust impact on reducing the symptoms of disabling claudication and rest pain caused by peripheral vascular disease.

Sources of error in the measurement of aortic diameter in computed tomography scans.

OBJECTIVE: This study was conducted to determine the differences in the diameter of the thoracic aorta when measured from electrocardiographic (ECG)-gated and nongated computed tomography (CT) angiography. Another aim was to define the difference in the aortic diameter when it is measured at peak systole and end diastole in ECG-gated scans. METHODS: The gated and nongated CT angiograms of 27 patients (mean age, 58 ± 16 standard deviation [SD] years) obtained on a 256-slice multidetector CT scanner were used. The transverse and anteroposterior diameters and the lumen areas were measured at 1, 4, and 8 cm below the origin of the left subclavian artery. RESULTS: There was a significant difference in the aortic measurements of diameter between gated and nongated scans found in samples taken at 1, 4, and 8 cm distal to the left subclavian artery (P < .0001). We found a considerable difference between the systolic and diastolic diameters (P < .0001). The maximum change in diameter between systole and diastole was 2.9 ± 0.9 (SD) mm (14.5%, P < .0001) at 1 cm, 5.4 mm (22.6%; median, 1.7 mm; P < .0001) at 4 cm, and 4.4 mm (16.9%; median, 1.3 mm; P < .0001) at 8 cm. There was a significant difference between the transverse and anteroposterior diameters in systole and diastole at all locations (P < .0001): The maximum change in diameter between transverse and anteroposterior diameters in systole was 5.4 ± 1.1 (SD) mm (15.7%, P < .0001) at 1 cm, 5.8 mm (19%; median, 1.4 mm; P < .0001) at 4 cm, and 5 mm (15%; median, 1.02 mm; P < .0001) at 8 cm. There was also a substantial difference between measuring the transverse diameter directly and deriving it from the lumen area (P < .0001). CONCLUSIONS: Our results showed an important difference between systolic and diastolic diameters measurements in ECG-gated scans. The standard protocol for measuring aortic diameters in gated scans of the thoracic aorta uses images at end diastole because the lack of wall motion at this time provides better resolution. This is likely to result in undersizing that, in some instances, may threaten stability and the proper seal of the stent graft. The dimensions of the aorta in a gated CT should be measured at peak systole rather than the conventional end diastole used today. Most medical centers use nongated CT or gated CT scans in end diastole to calculate sizes of endografts. In view of our findings, the latter method could result in potential complications.

Use of covered stents and endograft as a rescue treatment in a patient with a complex form of recurrent aortic coarctation.

We report our experience with one patient with recurrent coarctation and aneurysm degeneration treated endoluminally. A novel technique was used combining balloon-expandable with self-expandable endografts. The balloon-expandable component expanded the area of stenosis and also created a neck to allow the implantation of the self-expandable endograft to exclude the aneurysm. Mismatch of diameters was solved with the creation of a new proximal neck, in which the distal end was progressively expanded to reach the appropriate diameter to implant the self-expandable endograft inside. Expansion of the narrow stenosis and complete exclusion of the aneurysm was achieved without a residual pressure gradient.

Heme oxygenase-1 is expressed in carotid atherosclerotic plaques infected by Helicobacter pylori and is more prevalent in asymptomatic subjects.

BACKGROUND AND PURPOSE: It is not well established what are the features, if any, that distinguish symptomatic from asymptomatic carotid atherosclerotic plaques. Inducible heme oxygenase-1 (HO-1) is a component of cellular defense mechanisms against oxidative stress. We aimed to assess the presence of Helicobacter pylori (H pylori) and the expression of HO-1 in carotid atherosclerotic plaques of patients with and without prior neurologic symptoms attributable to the operated artery. METHODS: We examined 25 symptomatic and 23 asymptomatic carotid atherosclerotic plaques removed during endarterectomy and 7 normal carotid arteries obtained at autopsy. We investigated the presence of H pylori DNA in the vessel wall and performed immunohistochemical detection of HO-1. RESULTS: H pylori DNA was present in 28 plaques and HO-1 was expressed in 30 plaques. HO-1 was found in 27 H pylori-positive specimens but in only 3 H pylori-negative specimens (P<0.001). All 7 normal carotid arteries were negative for both H pylori and HO-1. Although 82% of asymptomatic specimens were positive for H pylori and 87% for HO-1, only 36% of symptomatic specimens were positive for both H pylori and HO-1 (P<0.01). CONCLUSIONS: This study suggests a strong association between H pylori infection and expression of HO-1 in carotid atherosclerotic plaques. There was a substantial prevalence of these features in specimens obtained from asymptomatic subjects.

1992: Parodi, Montefiore, and the first abdominal aortic aneurysm stent graft in the United States.

In 1990 Juan C. Parodi performed the first endovascular abdominal aortic aneurysm (AAA) repair in Buenos Aires. Two years later, in 1992, Parodi and Claudio Schonholz visited Montefiore Medical Center in New York to perform with us the first endovascular AAA repair to be done in the United States. Since then the Montefiore/Einstein vascular group has performed 1522 endovascular grafts in 674 patients for many types of vascular lesions using a variety of both surgeon-made and industry-made devices. The purpose of the present article is to describe the events that surrounded the performance of the first seminal endovascular AAA repair at our institution on November 23, 1992.

Cerebral protection during carotid stenting using flow reversal.

BACKGROUND: Carotid angioplasty and stenting can be used in stroke prevention in high-risk patients. As embolic complications can occur during carotid angioplasty and stenting, a device was developed to protect from cerebral embolization. METHODS: Between September 1999 and May 2002, carotid angioplasty and stenting was performed in 100 patients (84 men; mean age, 69.2 years) with symptomatic (26%) or asymptomatic (74%) severe carotid artery stenosis. Wallstents were used in all cases with selective pre-dilatation. Cerebral protection devices (Parodi Anti-Emboli System [PAES], ArteriA, San Francisco, Calif) were used in all patients. All patients were evaluated by a neurologist, both before and after the procedure. According to the criteria set forth by the large trials, the occurrence of minor, major or fatal stroke and myocardial infarction (end points) within 30 days and follow-up were determined as end points. Data were collected prospectively. RESULTS: The overall perioperative stroke and death rate was 3% (1 noncorresponding minor stroke, 1 hemorrhagic stroke, and 1 cardiac event). Four patients developed postoperative transient neurologic events (three related to hemodynamic instability and the fourth due to postoperative embolization). The overall technical success rate for carotid angioplasty (protection device placed in position percutaneously) was 99%. CONCLUSION: The efficacy and safety of carotid angioplasty and stenting with PAES are confirmed. This innovative protection device may prevent the debris released by angioplasty from entering the cerebral circulation. Further investigation is warranted.