Associations Between Systolic Pressure, Vascular Waveform, and Volume Flow with Debridement or Amputation Treatment Decisions in Diabetic Foot Ulcer Patients.

INTRODUCTION: Diabetic foot ulcer disease, affecting 6.3% of the global population, necessitates crucial decisions regarding debridement and amputation, with substantial cost, morbidity, and mortality implications. This study's primary goal is to determine effective vascular examination modalities, including systolic blood pressure, vascular waveforms, and blood volume flow to guide optimal treatments for diabetic foot patients. METHOD: This cross-sectional study at Cipto Mangunkusumo General Hospital aimed to identify effective vascular examination modalities, such as systolic blood pressure, vascular waveforms, and blood volume flow, to guide treatment choices for diabetic foot patients. The study included 38 subjects, equally split between debridement and amputation groups. RESULTS: Notably, the presence of a biphasic pattern in popliteal artery vascular examinations was associated with the decision for amputation in diabetic foot patients (p < 0.05). The Chi-square test revealed that a biphasic ultrasound pattern served as a predictive factor for amputation among diabetic foot patients, with three times more biphasic patients choosing amputation over debridement. Conversely, assessments of popliteal artery systolic pressure, common femoral artery waveform, popliteal artery volume flow, and common femoral artery volume flow showed no significant correlations with the choice of debridement or amputation treatment for diabetic foot patients. CONCLUSION: In summary, ultrasound assessment of vascular waveform in the popliteal artery emerges as a predictive factor for amputation or debridement in diabetic foot patients.

Brachiocephalic arteriovenous fistula maturity in end stage renal disease: The role of intraoperative brachial artery blood flow rate and peak systolic velocity.

Introduction: Arteriovenous fistula (AVF) is the preferred vascular access option due to its lower risk of complications and better long-term outcomes. However, AVF maturation failure is still quite high. Achieving an adequate blood flow rate (BFR) through the AVF is essential for maintaining hemodialysis adequacy. This study aims to investigate brachial artery intraoperative BFR and peak systolic velocity (PSV) increase as a predictor of brachiocephalic AVF maturation. Methods: A multicenter retrospective cohort study was conducted on patients with end stage renal disease undergoing brachiocephalic AVF creation from July 2019 to February 2022 from five hospitals. Doppler ultrasound examinations of BFR and PSV were collected. BFR and PSV increases were calculated by comparing pre-operative and intraoperative results. Maturity was determined at 6 weeks postoperatively. Results: This study included 83 patients, with 50 patients (60.24%) achieving maturity at 6 weeks. Brachial artery BFR difference has an excellent diagnostic value to predict brachiocephalic AVF maturation with an area under the curve (AUC) of 97%. BFR increase of 184.58 ml/min predicts brachiocephalic AVF maturity with a sensitivity of 100%, specificity of 84.8%, and accuracy of 93.98%. Meanwhile, brachial artery PSV increase has a low diagnostic value to predict brachiocephalic AVF with an AUC of 71.2%. PSV increase of 8.97 cm/s predicts brachiocephalic AVF maturity with a sensitivity of 82%, specificity of 51.5%, and accuracy of 69.9%. Conclusion: The increase in intraoperative brachial artery BFR and PSV in brachiocephalic AVF can be used as a useful parameter to predict AVF maturation.

Risk Factors of Asymptomatic Carotid Artery Disease in Geriatric Evaluated Using Carotid Intima-Media Thickness (IMT) Measurement, the First Indonesian Population Study.

Carotid artery disease in geriatric is one of the important etiologies of stroke, which topped the cause of mortality in Indonesia. Specific prevention should be done as early as asymptomatic disease occurred. Initial assessment can be performed using ultrasound by measuring the intima-media thickness (IMT) of carotid artery, which can evaluate earlier progression of the atherosclerosis process. Unfortunately, we do not have risk factors categorization that show us which geriatric population fall under high-risk stratification to be screened. Study was done to Indonesian geriatric population. Asymptomatic carotid disease was tested positive if IMT was > 0.9 mm without any previous neurological symptoms. Correlation of the result was statistically tested with risk factors of atherosclerotic process, such as sex, body mass index, presence of hypertension, diabetes mellitus, and hypercholesterolemia. Study obtained 104 subjects and showed the prevalence of asymptomatic carotid disease was 37.5%. Two risk factors: diabetes mellitus and hypercholesterolemia were statistically significant ( p = 0.01) with odds ratio (OR) 3.56 (1.31-9.64, 95% confidence interval [CI]) and OR 2.85 (1.25-6.51, CI 95%), respectively. Logistic regression showed the risk was 69.2% by having two of these comorbidities, 47.2 or 42.5% if diabetes mellitus or hypercholesterolemia was present. As diabetes mellitus and hypercholesterolemia were proved to be significant risk factors for asymptomatic carotid artery disease, we recommend performing ultrasound screening to measure carotid artery IMT for geriatric population who had diabetes mellitus and/or hypercholesterolemia for asymptomatic carotid artery disease to be diagnosed and further treated.

The Correlation of Short-Chain Fatty Acids with Peripheral Arterial Disease in Diabetes Mellitus Patients.

Diabetes mellitus (DM) is a significant risk factor for peripheral arterial disease (PAD). PAD affects 20% of DM patients over 40 and has increased by 29% in the last 50 years. The gut microbiota produces short-chain fatty acids (SCFAs) that affect atherosclerosis. SCFA inhibits inflammation, which contributes to atherosclerosis. This study tried to link feces SCFA levels to atherosclerosis in people with diabetes with peripheral arterial disease (PAD). The study included 53 people with diabetes and PAD: gas chromatography-mass spectrometry measured acetate, butyrate, and propionate levels in feces samples (GC-MS). There was a positive correlation between random blood glucose (RBG) levels, peak systolic velocity (PSV), volume flow (VF), plaque, relative and absolute acetate, relative valerate, butyrate, and propionate. This supports the idea that elevated SCFA levels in type 2 diabetic (T2D) patients reduce adipose tissue inflammation and cholesterol metabolism, contributing to atherosclerosis pathogenesis. We conclude that increased fecal SCFA excretion is linked to cardiovascular disease. To determine the causal effect correlation of the SCFA with clinical and laboratory parameters for PAD in DM patients, compare the SCFA in plasma and feces, and account for confounding variables, a specific method with larger sample sizes and more extended follow-up periods is required.

Effect of primary balloon angioplasty on draining vein diameter and volume flow in patients with arteriovenous fistula: A cohort study.

Background: Chronic kidney disease (CKD) and end-stage kidney disease (ESKD) cause major morbidity and mortality in 10% of the global population with CKD. The most common renal replacement therapy is hemodialysis with arteriovenous fistula (AVF) access. AVF often undergoes maturation failure due to feeding artery and draining vein inadequacy. Mechanical dilatation, such as primary balloon angioplasty (PBA), can overcome AVF maturation failure. The volume flow (VF) and diameter of the draining veins in AVF patients must be known to evaluate the effect of PBA on AVF maturation. This study aims to analyze the impact of PBA on VF and draining vein diameter in ESKD patients undergoing AVF surgery. Methods: A retrospective cohort clinical trial was conducted at our institution. A total of 75 participants had AVF with an arterial diameter >1.5 mm or vein diameter at the AVF creation site of 2-4 mm. The subjects were divided into 2 groups: the intervention group undergoing PBA (n = 36) and the control group, without PBA (n = 39). PBA was performed using a Mustang ballon (3-6 mm, Medtronic). Follow-ups were conducted at 1 week, 2 weeks, and 6 weeks after AVF creation. Results: Based on the data, the diameter and VF of the draining veins were significantly larger in the intervention group than in the control group (p < 0.001). Furthermore, we found significant differences in the mean diameter and VF of the draining veins between the control and intervention groups at all stages of examination, from preoperatively to 6 weeks postoperatively (p < 0.001). The strength of the analysis was more than 80%. Conclusion: PBA can increase the diameter and VF of the draining veins in patients with AVF.

Characteristics of Diabetic Foot Ulcer Patients Pre- and During COVID-19 Pandemic: Lessons Learnt From a National Referral Hospital in Indonesia.

BACKGROUND: Diabetic foot ulcer (DFU) is one of the most terrifying diabetic complications for patients, due to the high mortality rate and risk for amputation. During the COVID-19 pandemic, many diabetic patients limited their visits to the hospital, resulting in delays for treatment especially in emergency cases. OBJECTIVE: This study aimed to compare the characteristics of patients with DFU pre- and during COVID-19 pandemic period. Methods: This study was a retrospective cohort study using foot registry data. We compared our patients' characteristics pre-COVID-19 pandemic period (1 March 2019-28 February 2020) and during COVID-19 pandemic period (1 March 2020-28 February 2021). RESULTS: Cohorts of 84 and 71 patients with DFU pre- and during COVID-19 pandemic period, respectively, were included in this study. High infection grade (66.7% vs 83.1%, P = .032), osteomyelitis event (72.6% vs 87.3%, P = .04), leukocyte count (15 565.0/µL vs 20 280.0/µL, P = .002), neutrophil-to-lymphocyte ratio (7.7 vs 12.1, P = .008), waiting time-to-surgery (39.0 h vs 78.5 h, P = .034), and number of major amputation (20.2% vs 39.4%, P = .014) were significantly higher during the COVID-19 pandemic period. CONCLUSION: During the COVID-19 pandemic, patients with DFU had more severe infection, higher proportion of osteomyelitis, longer waiting time for getting surgical intervention, and higher incidence of major amputation.

Correlation of gut Firmicutes/Bacteroidetes ratio with fibrosis and steatosis stratified by body mass index in patients with non-alcoholic fatty liver disease.

We investigated the gut microbiota in patients with non-alcoholic fatty liver disease (NAFLD) and its correlation with fibrosis and steatosis stratified by body mass index, as reflected in the controlled attenuation parameter and transient elastography values. A cross-sectional study was performed on 37 patients with NAFLD at Cipto Mangunkusumo National General Hospital from December 2018 to March 2019. The gut microbiota was investigated in fecal samples with 16S RNA sequencing using the MiSeq next-generation sequencing platform (Illumina). NAFLD was more common in patients with metabolic syndrome. Firmicutes, Bacteroidetes, and Proteobacteria were the predominant phyla. Bacteroides was more dominant than Prevotella, contrary to the results of previous studies on healthy populations in Indonesia. Microbiota dysbiosis was observed in most samples. The gastrointestinal microbiota diversity was significantly decreased in patients with NAFLD, high triglyceride levels, and central obesity. The Firmicutes/Bacteroidetes ratio correlated with steatosis and obesity, whereas some of the other species in lower taxonomy levels were mostly associated with steatosis and obesity without fibrosis. Proteobacteria was the only phylum strongly correlated with fibrosis in patients with an average body mass index. The gut microbiota diversity was decreased in patients with NAFLD, high triglyceride levels, and central obesity, and certain gut microbes were correlated with fibrosis and steatosis.

Endoluminal dilatation technique to remove stuck hemodialysis tunneled catheter: A case report from Indonesia.

BACKGROUND: Tunneled CVC is being increasingly used worldwide as a mean of vascular access for hemodialysis. Among these, one of the emerging complications is that of the "embedded" or stuck catheter. There have been registered cases of vasomotor collapse, non-ST-elevation myocardial infarction (NSTEMI), avulsion of the vena cava, damage to the tricuspid valve having fatal consequences, and breakage of the CVC (Lodi et al., 2016). CASE PRESENTATION: A 63-year-old female with mature AV fistula came to the clinic for removal of a tunnelled 15 fr double lumen dialysis catheter (Medical Components, Harleysville, Pensylvania) that had been inserted into the left internal jugular vein 15 months prior to this visit. In the OR, our surgical attempt to remove the catheter failed. The first few dilation procedures were performed using 0.035-inch guidewire and balloon catheters. The technique was subsequently modified as follows. In this case we use a 6 × 60 mm Scoreflex balloon. Endoluminal dilation was repeated along the length of the catheter up to the cuff. Once the catheter has been removed, pressure was applied using sterile gauze to aid hemostasis. The procedure was successful without any observed complication. CONCLUSION: Endoluminal dilatation technique is considered as the easiest and safest technique to remove hemodialysis catheter. Our case is the first stuck hemodialysis catheter reported in Indonesia and probably the first case that happen and treat with endoluminal dilatation technique in our country.

Effectiveness of Doppler Ultrasonography as a Predictor of Wound Healing after Below-Knee Amputation for Peripheral Arterial Disease.

Background: tool is needed to predict how wound following below-knee amputation (BKA) surgery will heal in patient with peripheral artery disease (PAD). Ultrasonography is an alternative to evaluate the condition of the arteries. We conducted a study to investigate the association between doppler ultrasonography as pre-amputation assessment with primary wound healing following BKA surgery. Methods: A case-control study was conducted to investigate the effectiveness of ultrasonography as a predictor of the wound healing. Bivariate and multivariate analysis were performed to explore association between ultrasonography indicators including peak systolic velocity, volume flow, arterial diameter, and distal artery spectral waveform with wound healing following BKA. Ultrasonography assessments were conducted on the popliteal artery, anterior tibial artery, and posterior tibial artery. Results: Based on the multivariate analysis on all arteries, there were statistically significant associations of peak systolic velocity (adjusted odd ratio [OR]= 5.584, 95% confidence interval [CI]= 1.291 24.157, p= 0.021), volume flow (adjusted OR= 4.760, 95% CI= 1.200 18.876, p= 0.026), and arterial diameter (adjusted OR= 6.507, 95% CI= 1.510 - 28.033, p= 0.012) with wound healing after BKA. Conclusions: Doppler ultrasonography of PAD can be used as a predictive pre-amputation testing modality to predict wound healing after BKA.

Management of type II endoleak after endovascular repair of arteriocaval fistula complicating aortoiliac aneurysm: case report and literature review.

Endovascular treatment for arteriocaval fistula (ACF) has become the preferred alternative to open repair. However, endoleaks sometimes occur and maintain the ACF. A 64-year-old man presented with persistent fistula after placement of a bifurcated stent-graft for ACF complicating an aortoiliac aneurysm that was maintained by endoleaks from the inferior mesenteric and lumbar arteries. Transarterial embolization of the aneurysm sac and inferior mesenteric artery successfully resolved the problem without any complications observed over 16 months of follow-up. A literature review and discussion of the management options for this entity are presented. A combination of inflow and outflow control is important to obtain better long-term outcomes.

Modified interventional obliteration for variceal hemorrhage from elevated jejunum after pylorus-preserving pancreatoduodenectomy.

Ectopic variceal hemorrhage caused by sinistral portal hypertension after splenic vein ligation during a pyloric-preserving pancreatoduodenectomy is a rare entity. We report the case of a 58-year-old man with symptoms of refractory melena. The varices could not be treated endoscopically and surgery was considered unsuitable due to severe adhesions and altered anatomy. Following clinical failure of partial splenic embolization, an alternative obliteration method by a retrograde trans-portal-venous approach was successfully performed and resolved the problem. It seems to be an effective method for ectopic variceal bleeding, especially when other interventions are unavailable or highly risky.

Inhibition of growth in a rabbit VX2 thigh tumor model with intraarterial infusion of carbon dioxide-saturated solution.

PURPOSE: To evaluate the efficacy of intraarterial infusion of CO2-saturated solution in rabbit VX2 thigh tumors. MATERIALS AND METHODS: Fourteen Japanese white rabbits had VX2 tumors implanted in the right femoral muscle 3 weeks before intraarterial infusion. Rabbits were divided into control and CO2 groups (n = 7 each). Fifty milliliters of solution (saline solution and CO2-saturated solution for the control and CO2 groups, respectively) was administered via a 24-gauge catheter in the ipsilateral iliac artery close to the feeding artery of the VX2 tumor. All rabbits were killed for tumor harvest on day 3 after the procedure. Tumor volume was evaluated with in vivo direct caliper measurement and contrast-enhanced computed tomography (CT). Tumor apoptotic changes were examined by DNA fragmentation assay and immunoblot analysis. The tumor growth ratio and apoptotic cell rate were analyzed. RESULTS: Body weight was equally increased in both groups, but the mean tumor growth ratio was significantly decreased in the CO2 group compared with the control group (-9.5% ± 7.9 vs 27.2% ± 6.6 and 4.1% ± 4.4 vs 35.7% ± 4.5 measured by calipers and contrast-enhanced CT, respectively; P < .01). Apoptotic activity in the CO2 group was higher than in the control group (number of apoptotic cells per area, 215.0 ± 58.7 vs 21.8 ± 5.4; adjusted relative density of cleaved caspase-3, 0.23 ± 0.07 vs 0.04 ± 0.01; P < .01). CONCLUSIONS: Intraarterial infusion of CO2-saturated solution inhibits rabbit VX2 thigh tumor growth by activation of apoptotic cell death through cleaved caspase-3 upregulation.

Hybrid management for spontaneous isolated dissection of the iliofemoral artery.

Acute spontaneous and isolated dissection of the iliofemoral artery is an extremely rare entity. Conservative, surgical, and endovascular treatment have been used to treat such cases. To the best of our knowledge we report the first case of using hybrid management to successfully treat isolated external iliac artery dissection extending to the superficial femoral artery. This method could potentially overcome the limitations of endovascular techniques and minimize use of extensive open surgery.

Technical and outcome considerations of endovascular treatment for internal iliac artery aneurysms.

PURPOSE: This study was designed to analyze the outcomes of endovascular treatment for internal iliac artery aneurysm (IIAA) at mid-term follow-up. METHODS: We retrospectively analyzed 33 patients (28 males, mean age 77.4 years) who underwent endovascular treatment of 35 IIAAs (mean diameter 39.8 mm) from 2002 to 2012. We attempted to completely and selectively embolize all distal branches with permanent embolic materials, followed by proximal controls either by stent-graft placement (type 1) or coil embolization (type 2). RESULTS: Procedural success rate was 97.1% (n = 34). Complete permanent distal branches embolization was achieved in 27 (79.4%), type 1 in 24 (70.6%), and type 2 in 10 (29.4%) cases. During mean follow-up period of 29.1 months (range, 1.2-92.8), no IIAA-related mortality and stent/stent-graft related complications occurred. Pelvic ischemia occurred and resolved in 8 (25%) patients. Among 32 cases followed by CT, the aneurysm diameter was stable in 18 (56.3%), shrank in 11 (34.4%), and enlarged in 3 (9.4%) cases. In 22 assessed by contrast-enhanced CT, secondary endoleak occurred in 3 (13.6%) cases and 2 required secondary interventions (2/32, 6.3%). Type 1 procedure tends to have better mid-term outcomes. Incomplete permanent distal branches embolization was associated with enlargement and secondary intervention (p = 0.007 and p = 0.042, respectively). The secondary intervention-free rate at 3 years in the complete and incomplete distal embolization group was 100 and 83.3%, respectively (p = 0.128). CONCLUSIONS: Endovascular treatment for IIAA is feasible and safe. Complete permanent distal branches embolization is important to achieve satisfactory mid-term outcomes.

Successful n-butyl cyanoacrylate embolization of a spontaneous rupture of the internal mammary artery in a patient with myelodysplastic syndrome: report of a case.

Hemomediastinum and hemothorax due to spontaneous internal mammary artery (IMA) rupture is extremely rare, and can be a life-threatening condition. We herein present, to the best of our knowledge, the first case of spontaneous IMA rupture complicating myelodysplastic syndrome, and the first case that was successfully treated by emergency trans-arterial embolization using n-butyl cyanoacrylate.

Iliac leg and abdominal aortic cuff stent-graft for blunt thoracic aortic injury in young patient.

Thoracic endovascular aortic repair for blunt thoracic aortic injury in young adults with small aortic diameter often encounters high difficulty. We report, to our knowledge, the first case of successful treatment using combination of iliac leg and abdominal aortic cuff stent-graft.

Lessons learned from endovascular management of ureteroarterial fistula.

Stent graft placement for ureteroarterial fistula is the preferred treatment. However, some pitfalls may occur during the procedure. Chronic inflammation process will induce longer adhesion area between artery and ureter, which results in unusual fistula site and rigid iliac arteries. This further leads to difficulty in advancing the endograft delivery system, even when access route is large enough. Multiple attempts to pass the iliac artery may result in "incidental" mechanical provocative angiography with subsequent massive bleeding. These suggested us not only to be careful and prepared but also to consider that angiography after inserting the delivery system could give additional information on the exact fistula site.

Secondary aortoesophageal fistula after thoracic endovascular aortic repair for a huge aneurysm.

Thoracic endovascular aortic repair for a descending thoracic aortic aneurysm is an excellent alternative to open surgery, especially in patients with a number of comorbidities. It may cause fatal complications, including aortoesophageal fistula, but these are very rare. Here, we report the case of secondary aortoesophageal fistula four months after the procedure for a huge descending thoracic aortic aneurysm, which presented with new-onset high-grade fever accompanied by elevated inflammatory markers.

Long-term results of endovascular stent graft placement of ureteroarterial fistula.

PURPOSE: To evaluate the safety, efficacy, and long-term results of endovascular stent graft placement for ureteroarterial fistula (UAF). METHODS: We retrospectively analyzed stent graft placement for UAF performed at our institution from 2004 to 2012. Fistula location was assessed by contrast-enhanced computed tomography (CT) and angiography, and freedom from hematuria recurrence and mortality rates were estimated. RESULTS: Stent graft placement for 11 UAFs was performed (4 men, mean age 72.8 ± 11.6 years). Some risk factors were present, including long-term ureteral stenting in 10 (91%), pelvic surgery in 8 (73%), and pelvic radiation in 5 (45%). Contrast-enhanced CT and/or angiography revealed fistula or encasement of the artery in 6 cases (55%). In the remaining 5 (45%), angiography revealed no abnormality, and the suspected fistula site was at the crossing area between urinary tract and artery. All procedures were successful. However, one patient died of urosepsis 37 days after the procedure. At a mean follow-up of 548 (range 35-1,386) days, 4 patients (36%) had recurrent hematuria, and two of them underwent additional treatment with secondary stent graft placement and surgical reconstruction. The hematuria recurrence-free rates at 1 and 2 years were 76.2 and 40.6%, respectively. The freedom from UAF-related and overall mortality rates at 2 years were 85.7 and 54.9%, respectively. CONCLUSION: Endovascular stent graft placement for UAF is a safe and effective method to manage acute events. However, the hematuria recurrence rate remains high. A further study of long-term results in larger number of patients is necessary.