Relationship between soluble thrombomodulin in patients with intermittent claudication and critical ischemia.

INTRODUCTION: Thrombomodulin (TM) has been described as a marker of endothelial injury in atherosclerosis. The role of TM as a predictor of PAD severity is to be proven. The goal of the present study is to compare the level of plasmatic (TMp) in patients with intermittent claudication with patients with critical ischemia in the lower limbs. MATERIALS AND METHODS: TMp was measured using ELISA in the plasma of 41 patients with intermittent claudication degree 1 and in 40 patients presenting critical ischemia in the lower limbs degrees 2 and 3, according to TASC. The hypotheses of normality and homogeneity of the variance had been proven via Shapiro-Wilk and Levene tests, respectively. The comparison of the TMp between the groups was done using the t-Student test. RESULTS: No statistically significant difference was observed. The average levels of TMp for intermittent claudication were 5.2 ng/ml (0.78-13.61 ng/ml) and TMp for critical ischemia in the lower limbs were 6.34 (0.82-18.22 ng/ml) where p=0.265. CONCLUSION: TMp does not seem to be an appropriate marker for PAD severity.

Use of arteriography for the initial evaluation of patients with intermittent lower limb claudication.

CONTEXT: Many patients with intermittent claudication continue to be forwarded to the vascular surgeon for initial evaluation after arteriography has already been accomplished. OBJECTIVE: The main objective of this work was to analyze the usefulness and the need for this procedure. TYPE OF STUDY: Retrospective study. SETTING: The patients were divided into two groups: Group 1, with the arteriography already performed and Group 2 without the initial arteriography. PARTICIPANTS: One hundred patients with intermittent claudication were retrospectively studied. Other specialists had forwarded them for the first evaluation of intermittent claudication, without any previous treatment. MAIN MEASUREMENTS: All patients were treated clinically for at least a 6-month period. The total number of arteriographies performed in the two groups was compared and the need and usefulness of the initial arteriography (of Group 1) was also analyzed. RESULTS: The evolution was similar for both groups. The total number of arteriographies was significantly higher in Group 1 (Group 1 with 53 arteriographies vs. Group 2 with 7 arteriographies). For this group, it was found that arteriography was only useful in five cases (10%), because the surgeries were based on their findings. However, even in those cases, no need for arteriography was observed, as the procedure could have been performed at the time of surgical indication. CONCLUSION: There are no indications for arteriography in the early evaluation of patients with intermittent claudication, because it does not modify the initial therapy, independent of its result. In cases where surgical treatment is indicated, this procedure should only be performed prior to surgery.

Predictive value of the ankle-brachial index in the evaluation of intermittent claudication.

The purpose of this study was to determine whether the ankle-brachial index (ABI) could be used to predict the prognosis for a patient with intermittent claudication (IC). We studied 611 patients prospectively during 28 months of follow-up. We analyzed the predictive power of using various levels of ABI - 0.30 to 0.70 at 0.05 increments - in terms of the measure's specificity (association with a favorable outcome after exercise rehabilitation therapy) and sensitivity (association with a poor outcome after exercise rehabilitation therapy). We found that using an ABI of 0.30 as a cut-off value produced the lowest margin of error overall, but the predictive power was still low with respect to identifying the patients with a poor prognosis after non-aggressive therapeutic treatment. Further study is needed to perhaps identify a second factor that could increase the sensitivity of the test.

Surgical treatment of noniatrogenic trauma of the femoral arteries.

Trauma to the femoral arteries corresponds to 30 percent of all arterial traumas. The authors reviewed 74 patients with noniatrogenic trauma of the femoral arteries treated from January 1991 to December 1993. Ages ranged from 11 to 50 years, with a mean of 24. Seventy-one patients were male and three female. Fifty-two patients (70.2 percent) were white, 20 (27 percent) were black and two (2.8 percent) were Asian. Trauma due to firearms had the highest incidence, with 61 cases (82.4 percent). Absence of pulse was the most frequent clinical symptom (62.5 percent). Severe ischemia, with risk of loss of limb, was found in 66.2 percent of the cases. The superficial femoral artery was impaired in 77 percent of the cases. A preoperative arteriography was performed on only five patients, victims of multiple penetrating trauma or an asymptomatic penetrating wound along a vessel passage. In six cases, arterial and venous ligature was the chosen procedure. In three cases, a primary arterial anantomosis was performed. Simple arterriorraphy was feasible in one patient. In 64 of the patients, a venous graft was undertaken using a segment of the inverted great saphenous vein withdrawn from the other lower limb. Fasciotomoy was used in 32 patients (43.2 percent), all of whom exhibited pasting of the lower limb muscles at admission. One patient died during the immediate postoperative period as the result of multiple organ failure caused by polytraumatism. Preservation of the limb was attained in 72 patients (97.3 percent) Severe, previously-incurred ischemia was responsible for the only two amputations, aggravated by an exceedingly long delay between the time of injury and surgery. One of these patients, in addition to severe ischemia, had extensive injuries to the soft tissues. We conclude that trauma of the femoral arteries, attended while the limb still maintains its vitality, has a positive clinical outcome with a high rate of limb preservation. Mortality usually results from injury to other organs.