Correlation Between Cutaneous Manifestations and Functional Alterations in Chronic Venous Disease of the Lower Extremities / Correlación entre las manifestaciones cutáneas y las alteraciones funcionales en la insuficiencia venosa crónica en las extremidades inferiores

Background and aims Few studies have evaluated the correlation between the severity of cutaneous manifestations of chronic venous disease (CVD) of the lower limbs measured by the Clinical, Etiologic, Anatomic and Pathophysiologic classification (CEAP) and the Venous Clinical Severity Score (VCSS) combined, its risk factors, and venous reflux determined by Doppler ultrasonography. The purpose of this study was to compare the clinical severity assessed by CEAP and VCSS with known risk factors for CVD and the severity of venous reflux. Methods A prospective study was carried out on 250 patients with CVD characterized as C2 to C6 according to the CEAP classification, who attended the departments of Dermatology and Vascular Medicine at the Hospital Privado Universitario de Córdoba from April 2013 to December 2014. Chi-square test, Kruskal–Wallis analysis and multivariate logistic regression analysis were performed to examine the relations between these variables. Result Risk factors significantly associated with clinical severity included older age, hypertension, obesity, sedentarism, history of soft tissue infection, deep vein thrombosis (DVT), previous ulcer, and family history of venous ulcer. Both scores showed a good correlation between clinical severity and the presence of superficial, deep or perforating venous reflux. Older age, male gender and a history of DVT were significant risk factors for venous reflux in patients with mild disease. Conclusions In addition to venous reflux, modifiable risk factors such as obesity, sedentarism, and hypertension are associated with CVD severity. Mild cutaneous manifestations may accompany moderate to severe venous reflux, especially in middle-aged or older men with a history of DVT (AU)

Antecedentes y objetivos Pocos estudios han evaluado la correlación entre la gravedad de las manifestaciones cutáneas de la insuficiencia venosa crónica (IVC) en las extremidades inferiores medida conjuntamente utilizando la clasificación Clinical, Etiologic, Anatomic and Pathophysiologic classification (CEAP) y Venous Clinical Severity Score (VCSS), sus factores de riesgo y el flujo venoso determinado mediante ecografía Doppler. El objetivo de este estudio fue comparar la gravedad clínica evaluada mediante CEAP y VCSS y los factores de riesgo conocidos para IVC y la gravedad del reflujo venoso. Métodos Se llevó a cabo un estudio prospectivo de 250 pacientes con IVC caracterizada de C2 a C6 conforme a la clasificación CEAP, que acudieron a los departamentos de Dermatología y Medicina Vascular del Hospital Privado Universitario de Córdoba de abril de 2013 a diciembre de 2014. Se realizaron las pruebas χ2 y Kruskal-Wallis, así como un análisis de regresión logística multivariante para examinar las relaciones entre estas variables. Resultados Los factores significativamente asociados a la gravedad clínica fueron: edad avanzada, hipertensión, obesidad, sedentarismo, historia de infección de tejidos blandos, trombosis venosa profunda (TVP), úlcera previa y antecedentes familiares de úlcera venosa. Ambas puntuaciones reflejaron una buena correlación entre la gravedad clínica y la presencia de reflujo venoso superficial, profundo o perforante. La edad avanzada, el sexo masculino y los antecedentes de TVP fueron factores de riesgo significativos para el reflujo venoso en los pacientes con enfermedad leve. Conclusiones Además del reflujo venoso, los factores de riesgo moderado modificables, tales como la obesidad, el sedentarismo y la hipertensión, están asociados a la gravedad de la IVC. Las manifestaciones cutáneas leves pueden acompañar al reflujo venoso de moderado a severo, especialmente en los varones de mediana edad, o edad avanzada, con antecedentes de TVP (AU)

[Artículo traducido] Correlación entre las manifestaciones cutáneas y las alteraciones funcionales en la insuficiencia venosa crónica en las extremidades inferiores / Correlation Between Cutaneous Manifestations and Functional Alterations in Chronic Venous Disease of the Lower Extremities

Antecedentes y objetivos Pocos estudios han evaluado la correlación entre la gravedad de las manifestaciones cutáneas de la insuficiencia venosa crónica (IVC) en las extremidades inferiores medida conjuntamente utilizando la clasificación Clinical, Etiologic, Anatomic and Pathophysiologic classification (CEAP) y Venous Clinical Severity Score (VCSS), sus factores de riesgo y el flujo venoso determinado mediante ecografía Doppler. El objetivo de este estudio fue comparar la gravedad clínica evaluada mediante CEAP y VCSS y los factores de riesgo conocidos para IVC y la gravedad del reflujo venoso. Métodos Se llevó a cabo un estudio prospectivo de 250 pacientes con IVC caracterizada de C2 a C6 conforme a la clasificación CEAP, que acudieron a los departamentos de Dermatología y Medicina Vascular del Hospital Privado Universitario de Córdoba de abril de 2013 a diciembre de 2014. Se realizaron las pruebas χ2 y Kruskal-Wallis, así como un análisis de regresión logística multivariante para examinar las relaciones entre estas variables. Resultados Los factores significativamente asociados a la gravedad clínica fueron: edad avanzada, hipertensión, obesidad, sedentarismo, historia de infección de tejidos blandos, trombosis venosa profunda (TVP), úlcera previa y antecedentes familiares de úlcera venosa. Ambas puntuaciones reflejaron una buena correlación entre la gravedad clínica y la presencia de reflujo venoso superficial, profundo o perforante. La edad avanzada, el sexo masculino y los antecedentes de TVP fueron factores de riesgo significativos para el reflujo venoso en los pacientes con enfermedad leve. Conclusiones Además del reflujo venoso, los factores de riesgo moderado modificables, tales como la obesidad, el sedentarismo y la hipertensión, están asociados a la gravedad de la IVC. Las manifestaciones cutáneas leves pueden acompañar al reflujo venoso de moderado a severo, especialmente en los varones de mediana edad, o edad avanzada, con antecedentes de TVP (AU)

Background and aims Few studies have evaluated the correlation between the severity of cutaneous manifestations of chronic venous disease (CVD) of the lower limbs measured by the Clinical, Etiologic, Anatomic and Pathophysiologic classification (CEAP) and the Venous Clinical Severity Score (VCSS) combined, its risk factors, and venous reflux determined by Doppler ultrasonography. The purpose of this study was to compare the clinical severity assessed by CEAP and VCSS with known risk factors for CVD and the severity of venous reflux. Methods A prospective study was carried out on 250 patients with CVD characterized as C2 to C6 according to the CEAP classification, who attended the departments of Dermatology and Vascular Medicine at the Hospital Privado Universitario de Córdoba from April 2013 to December 2014. Chi-square test, Kruskal–Wallis analysis and multivariate logistic regression analysis were performed to examine the relations between these variables. Result Risk factors significantly associated with clinical severity included older age, hypertension, obesity, sedentarism, history of soft tissue infection, deep vein thrombosis (DVT), previous ulcer, and family history of venous ulcer. Both scores showed a good correlation between clinical severity and the presence of superficial, deep or perforating venous reflux. Older age, male gender and a history of DVT were significant risk factors for venous reflux in patients with mild disease. Conclusions In addition to venous reflux, modifiable risk factors such as obesity, sedentarism, and hypertension are associated with CVD severity. Mild cutaneous manifestations may accompany moderate to severe venous reflux, especially in middle-aged or older men with a history of DVT (AU)

Correlation Between Cutaneous Manifestations and Functional Alterations in Chronic Venous Disease of the Lower Extremities.

BACKGROUND AND AIMS: Few studies have evaluated the correlation between the severity of cutaneous manifestations of chronic venous disease (CVD) of the lower limbs measured by the Clinical, Etiologic, Anatomic and Pathophysiologic classification (CEAP) and the Venous Clinical Severity Score (VCSS) combined, its risk factors, and venous reflux determined by Doppler ultrasonography. The purpose of this study was to compare the clinical severity assessed by CEAP and VCSS with known risk factors for CVD and the severity of venous reflux. METHODS: A prospective study was carried out on 250 patients with CVD characterized as C2 to C6 according to the CEAP classification, who attended the departments of Dermatology and Vascular Medicine at the Hospital Privado Universitario de Córdoba from April 2013 to December 2014. Chi-square test, Kruskal-Wallis analysis and multivariate logistic regression analysis were performed to examine the relations between these variables. RESULTS: Risk factors significantly associated with clinical severity included older age, hypertension, obesity, sedentarism, history of soft tissue infection, deep vein thrombosis (DVT), previous ulcer, and family history of venous ulcer. Both scores showed a good correlation between clinical severity and the presence of superficial, deep or perforating venous reflux. Older age, male gender and a history of DVT were significant risk factors for venous reflux in patients with mild disease. CONCLUSIONS: In addition to venous reflux, modifiable risk factors such as obesity, sedentarism, and hypertension are associated with CVD severity. Mild cutaneous manifestations may accompany moderate to severe venous reflux, especially in middle-aged or older men with a history of DVT.

Symptomatic Venous Thromboembolism and Major Bleeding After Renal Transplantation: Should We Use Pharmacologic Thromboprophylaxis?

BACKGROUND: Venous thromboembolism (VTE) is a major health issue that may result in complications such as post-thrombotic syndrome, pulmonary hypertension, and death. Appropriate thromboprophylaxis in individuals undergoing kidney transplantation remains unclear. The aim of this study was to determine the prevalence of symptomatic VTE and major bleeding within 90 days after renal transplantation (RT). METHODS: This was a retrospective study on consecutive patients undergoing RT at Hospital Privado Córdoba, Argentina, from January 1, 2006, to December 31, 2013. Exclusion criteria were age <18 years and combined organ transplantation. Pharmacologic or mechanical thromboprophylaxis was not used routinely. Symptomatic VTE and major bleeding were documented. RESULTS: A total of 511 RTs were performed; 62 patients received combined organ transplantation, and 8 patients (1.5%) were lost to follow-up. Overall, follow-up was completed on 441 patients, 4 (0.9%) of whom developed deep venous thrombosis and 14 (3%) of whom died. The most frequent causes of death were septic shock and severe hemorrhage. Duration of surgery >4 hours (P = .006) and a history of VTE (P < .001) were associated with VTE. Twenty-three patients (5.2%) had major bleeding, 2 (0.4%) died from bleeding complications, and 17 (3.85%) required a reoperation to control bleeding. CONCLUSIONS: This study shows a low prevalence of symptomatic VTE in patients undergoing RT despite not having used thromboprophylaxis routinely. Major bleeding was significant, and despite the high risk of VTE assigned by the Caprini score, which suggests pharmacologic prophylaxis, our data raise questions about the appropriate prophylaxis for these patients.

Lung cavitation in primary antiphospholipid syndrome.

Pulmonary complications of primary antiphospholipid syndrome are common and diverse, with thromboembolic events counting as the most frequent manifestation. We present the case of a female patient with a diagnosis of primary antiphospholipid syndrome, pulmonary thromboembolism and infarction followed by lung cavitation.

Ischemic liver dysfunction after elective repair of infrarenal aortic aneurysm: incidence and outcome.

OBJECTIVE: To assess the frequency of early postoperative liver dysfunction in patients undergoing elective infrarenal aortic aneurysm repair, their hospital course, and outcome. DESIGN: A retrospective case-control study. SETTING: A single tertiary referral center. PARTICIPANTS: A review of medical records of 942 consecutive asymptomatic patients with normal preoperative liver function test results who had elective infrarenal aortic aneurysm repair with infrarenal aortic cross-clamping. The authors selected all patients who had an acute increase in serum hepatic enzyme levels (minimum fivefold increase in aspartate aminotransferase [AST] and twofold increase in lactate dehydrogenase [LDH] levels) within the first 7 perioperative days (study patients). The control group consisted of 42 patients with normal postoperative liver function test results, matched by age, sex, and year of surgery to study patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Aortic cross-clamping times, lowest intraoperative blood pressure, duration of hypotension (systolic blood pressure < or = 95 mmHg), lowest intraoperative base deficit, and estimated blood loss were compared between control and study patients. The study also analyzed perioperative metabolic, hemostatic, hepatic, and renal function variables; the intraoperative course; postoperative complications; and inhospital outcome. Fourteen of 942 patients (1.5%) comprised a study group. In 11 patients (1.2%), AST and LDH levels moderately increased, and three patients (0.3%) developed changes consistent with a diagnosis of acute ischemic hepatitis (AIH). In all patients, the serum liver enzyme levels peaked between 24 and 72 postoperative hours. Three patients with AIH developed concomitant acute renal failure; one had associated disseminated intravascular coagulation (DIC) and died. Of 11 patients with moderate increases, one subsequently developed multisystem organ failure and died. The overall in-hospital mortality rate for patients with postoperative liver dysfunction was 14% (2/14) and for the control group it was 2.3% (1/42). The duration of hypotension and metabolic acidosis were more pronounced in patients who postoperatively developed liver dysfunction (both p < 0.001); however, study and control patients did not differ in the duration of aortic cross-clamping, lowest intraoperative blood pressure, or estimated blood loss. CONCLUSION: Liver enzyme levels acutely increased in 1.5% of patients after elective infrarenal aortic aneurysm repair with infrarenal cross-clamping. In patients with moderately elevated serum liver enzyme levels, postoperative recovery was relatively uncomplicated, whereas all three patients with AIH developed acute renal failure and had a more complicated postoperative course. Those with postoperative liver dysfunction had a longer duration of intraoperative hypotension and more pronounced metabolic acidosis.

Disseminated intravascular coagulation associated with acute ischemic hepatitis after elective aortic aneurysm repair: comparative analysis of 10 cases.

OBJECTIVE: To assess the characteristics of patients with perioperative disseminated intravascular coagulation (DIC) and acute ischemic hepatitis after elective aortic aneurysm repair (AAR). DESIGN: A retrospective case-control study. SETTING: A single tertiary referral center. PARTICIPANTS: Between 1982 and 1993, 1966 patients underwent elective AAR. Of these, 10 patients (eight with abdominal and two with thoracoabdominal aneurysms) developed DIC and acute elevation of serum transaminases consistent with acute ischemic hepatitis during or shortly after surgery. The control group included 30 patients matched by age, sex, year of surgery, and aneurysm type and size. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: None of the patients in either group had preoperative hemostatic abnormalities or other causes for DIC. There was no difference between the two groups in the duration of aortic cross-clamping. In all study patients, severe coagulopathy or systemic hypotension developed after the aortic cross-clamp was released. This resulted in significantly increased surgery time after unclamping (p < 0.001), and increased estimated blood loss (p < 0.001). DIC developed within 24 hours, and mean concentrations of aspartate transaminase (4,021 +/- 3,579 IU/L) and lactate dehydrogenase (4,332 +/- 2,903 IU/L) peaked on the second postoperative day. Nine (90%) of the study patients required repeat operations (seven for bleeding), and all of them died; the median survival time was 6 days (mean, 8.3 +/- 8.2 days). Only one patient in the control group needed a repeat operation. Liver infarction or necrosis was seen in all seven patients who underwent autopsy or biopsy. CONCLUSIONS: The combination of DIC and acute ischemic hepatitis ("hepatohemorrhagic syndrome") rarely occurs after elective AAR and is associated with a very high mortality rate. DIC was temporally related to the release of the aortic cross-clamp. The cause-effect relationship of this rare syndrome cannot be explained by operative course before the release of the aortic cross-clamp.

Lower extremity arterial occlusions in young patients with Crohn's colitis and premature atherosclerosis: report of six cases.

Arterial occlusive disease (AOD) which is rarely described in patients with inflammatory bowel disease, is mainly associated with Crohn's disease (CD), and its etiology and natural course are unknown. We studied six patients (five women, one man) with CD and major lower extremity AOD who were treated at the Cleveland Clinic between 1985 and 1994. These were relatively young patients (age range 24-48 years) with steroid-dependent Crohn' colitis. On their presentation, five had acute onset of severe ischemic symptoms ("blue toe" syndrome in three) and one had rapid progression of claudication. All the patients had active CD and/or prior extensive bowel resections, and had no evidence of extraintestinal manifestation. Cardiovascular risk factors were smoking (n = 5), dyslipidemia (n = 3), family history of coronary artery disease (n = 3), premature menopause (n = 2), diabetes mellitus (n = 1). Arteriograms showed iliac artery involvement in all six patients and bilateral AOD in three. None of the patients had arteriographic or clinical signs of vasculitis. Five patients required arterial revascularizations, i.e., endovascular (n = 2), surgical (n = 2), and combined in one. Three patients had microscopic evidence of atherosclerosis. Lower extremity AOD in patients less than 50 yr of age and with CD may be partially related to premature atherosclerosis. Prospective screening for cardiovascular risk factors, subclinical disease, and hypercoagulability might be indicated in patients with active CD to prevent major arterial complications.