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REVIEW ARTICLE
Mesenchymal stem cell therapy for diabetic foot ulcer
Ying Liu, Yongquan Gu
April-June 2018, 1(1):1-5
DOI:10.4103/VIT.VIT_1_18  
Diabetic foot (DF) disease continues to be a major cause of mortality and disability. The pathophysiology of DF is multifactorial and includes neuropathy, infection, ischemia, and abnormal foot structure and biomechanics. Current therapies are limited; however, based on recent research efforts, there is rising hope for promising and more effective stem cell therapeutic approaches for these patients. In this review, we discuss mesenchymal stem cells as tools for cell/scaffold-based therapies for nonhealing wounds. We have reviewed the main clinical trials dividing them based on their clinical applications and taken into account the ethical issue associated with the stem cell therapy.
  5,672 342 -
REVIEW ARTICLES
Molecular targets for improving arteriovenous fistula maturation and patency
Jolanta Gorecka, Arash Fereydooni, Luis Gonzalez, Shin Rong Lee, Shirley Liu, Shun Ono, Jianbiao Xu, Jia Liu, Ryosuke Taniguchi, Yutaka Matsubara, Xixiang Gao, Mingjie Gao, John T Langford, Bogdan Yatsula, Alan Dardik
April-June 2019, 2(2):33-41
DOI:10.4103/VIT.VIT_9_19  
The increasing prevalence of chronic and end-stage renal disease creates an increased need for reliable vascular access; although arteriovenous fistulae (AVF) are the preferred mode of hemodialysis access, 60% fail to mature and only 50% remain patent at 1 year. Fistulae mature by diameter expansion and wall thickening; this outward remodeling of the venous wall in the fistula environment relies on a delicate balance of extracellular matrix remodeling, inflammation, growth factor secretion, and cell adhesion molecule upregulation in the venous wall. AVF failure occurs via two distinct mechanisms with early failure secondary to lack of outward remodeling, that is, insufficient diameter expansion or wall thickening, whereas late failure occurs with excessive wall thickening due to neointimal hyperplasia and insufficient diameter expansion in a previously functional fistula. In recent years, the molecular basis of AVF maturation and failure are becoming understood to develop potential therapeutic targets to aid maturation and prevent access loss. Erythropoietin-producing hepatocellular (Eph) carcinoma receptors, along with their ligands and ephrins, determine vascular identity and are critical for vascular remodeling in the embryo. Manipulation of Eph receptor signaling in adults, as well as downstream pathways, is a potential treatment strategy to improve the rates of AVF maturation and patency. This review examines our current understanding of molecular changes occurring following fistula creation, factors predictive of fistula success, and potential areas of intervention to decrease AVF failure.
  4,709 442 6
ORIGINAL ARTICLES
Aortic pulse wave velocity and augmentation [email protected] measured by oscillometric pulse wave analysis in Gujarati nonhypertensives
Jayesh Dalpatbhai Solanki, Hemant B Mehta, Chinmay J Shah
July-September 2018, 1(2):50-55
DOI:10.4103/VIT.VIT_10_18  
BACKGROUND: Augmentation indexes (AIxs) and pulse wave velocity (PWV) are arterial stiffness parameters. They can be studied by pulse wave analysis (PWA) noninvasively. Before use, AIx and PWV need normative baseline study to find the predictors. MATERIALS AND METHODS: We conducted a cross-sectional study in 801 nonhypertensives, aged 15–65 (divided into five subgroups) years. PWA was accomplished by Mobil-o-Graph (IEM, Germany) based on oscillometric principle and cardiovascular parameters reported were further analyzed. Value of P < 0.05 was taken as statistical significance. RESULTS: There were five age-based subgroups from 15 to 65 years, showing an increase in [email protected] and PWV with age. Females had significantly higher AIx in male in age groups (31.4 vs. 25.8, 34.95 vs. 27.21, 32.62 vs. 27.61, 34.32 vs. 26.36, 37.09 vs. 29.63; P < 0.05 for all), but PWV was higher in males than females in young age group (15–24 years-4.94 vs. 4.71, 25–34 years-5.28 vs. 5.12, 35–44 years-6.00 vs. 5.84; P < 0.05 in all) and in females than males in older age group (45–54 years-6.88 vs. 6.78,55–65 years-8.13 vs. 8.03). Major positive significant predictors of PWV were age, Body Mass Index, and systolic blood pressure; and of [email protected] were age, height (negative), heart rate, and pulse pressure. [email protected] and PWV showed a positive correlation with each other across all age group in either sex except for 55–65 years and 25–34 years age groups. CONCLUSIONS: Oscillometric measurement of PWV and [email protected] is feasible in our population. They are dependent on each other and age, totally not dependent on blood pressure and have difference in predictors. This baseline data can be used as a reference for future studies.
  4,081 416 4
The cardioprotective role of melatonin against myocardial injury in patients undergoing coronary artery bypass grafting surgery
Karrar H Dwaich, Fadhil G Al-Amran, Bassim I Al-Sheibani, Nasser Ghaly Yousif, Najah R Hadi
July-September 2018, 1(2):41-49
DOI:10.4103/VIT.VIT_12_18  
BACKGROUND: Myocardial ischemia/reperfusion injury associated with coronary artery bypass graft (CABG) surgery characterizes as a clinically critical problem. The incidence of oxidative stress, inflammation, and apoptosis are induced throughout the reperfusion of the cardiac muscles following ischemia. The present study aims to examine the protective role of melatonin in ameliorating the degree of myocardial injury in patients undergoing bypass surgery, and whether this effect is dose related. PATIENTS AND METHODS: A total of 45 patients who were undergoing CABG in (Al-Najaf Cardiac Center, Al-Najaf, Iraq) were enrolled in this study between January 2015 and November 2015. Patients were randomly allocated into three study groups: placebo-controlled group (C), low-dose melatonin treatment group, 10 mg capsule once daily (M1) and high-dose melatonin treatment group 20 mg capsule once daily (M2). RESULTS: Compared to the control group, there was a significant increase in the plasma level of melatonin associated with a significant reduction in plasma levels of high sensitive C-reactive protein, creatine kinase isoenzyme muscle/brain, and cardiac troponin-I, in the melatonin groups (Group M1 and M2) compared to the control group, (P < 0.05) in melatonin-treated groups. Comparing the two melatonin study groups, the changes in the parameters mentioned above were more significant in the M2 group compared to the M1 group (P < 0.05). CONCLUSION: These findings suggested that melatonin administration can ameliorate the degree of myocardial injury, dose-dependent effects.
  3,825 414 -
REVIEW ARTICLES
Venous circulation and William Harvey: A historical review
Kenneth Myers
April-June 2019, 2(2):42-50
DOI:10.4103/VIT.VIT_11_19  
Greco–Roman concepts regarding the circulation persisted until the 1600s even though many were incorrect. It was held that blood flows in veins from the liver to the periphery where it is consumed. It was not until the 1500s that anatomists identified venous valves and explored their function. This, in part, allowed William Harvey to describe the circulation as we know it today. This study included review of the literature and translations of William Harvey's books including De Motu Co]rdis which were published in 1628. Harvey's description of the venous circulation started the intense exploration of venous physiology that continues today. The resultant concepts of venous reflux associated with varicose disease have allowed practitioners to develop contemporary management.
  3,243 239 -
ORIGINAL ARTICLES
Critical role of Ghrelin in downregulation of the inflammatory response after renal injury
Teba Jasim Mohammed, Najah R Hadi, Israa Al-Yasiri, Nasser Ghaly Yousif, Abdullah Jasim, Fadhil Alamran, Ying Liu
July-September 2018, 1(2):68-73
DOI:10.4103/VIT.VIT_13_18  
BACKGROUND: The impairment of blood flow to the kidney causes renal injury occurs by ischemia/reperfusion (I/R) in surgical procedures, in which the kidneys remain without blood supply for sometime. This is observed during kidney transplantation, vascular surgery of aorta and renal arteries, and in partial nephrectomy. Ghrelin is an orexigenic growth hormone secretagogue of a 28 amino acid peptide derived mainly from ghrelinergic cells in the gastrointestinal tract. It plays an important physiological role in regulating of energy homeostasis and appetite stimulant. In this study, we aimed to assess the ability of ghrelin to exert potential protective effects on the kidney I/R and subsequent kidney dysfunctions in the rat through the modulation of pro-inflammatory cytokines. MATERIALS AND METHODS: A total of 28 rats were used in this experiment and the I/R was induced in a rat model by unilateral renal artery clamping for 30 min and reperfusion for 3 h, and ghrelin (40 μg/kg/rat) or vehicle was injected through intraperitoneal before ischemia and at reperfusion time immediately. Ghrelin administration could exert a protective role in the kidney against injury by significantly reducing serum and tissue levels of pro-inflammatory markers (tumor necrosis factor-alpha, high mobility group box protein 1, and interleukin 1 beta), decreasing the serum levels of (urea and creatinine), and reduction of the severity score of renal damage. CONCLUSIONS: We conclude that ghrelin has renoprotective effects through modulation of inflammation.
  3,097 375 -
Autologous tissue patches acquire vascular identity depending on the environment
Hualong Bai, Jianming Guo, Shirley Liu, Xiangjiang Guo, Haidi Hu, Tun Wang, Toshihiko Isaji, Shun Ono, Bogdan Yatsula, Ying Xing, Alan Dardik
April-June 2018, 1(1):14-23
DOI:10.4103/VIT.VIT_9_18  
Background: Vascular identity is genetically determined but can be altered during surgical procedures. Methods: We hypothesized that the environment of the procedure critically alters the identity of autologous tissue patches implanted into the arterial or venous environment. Results: Autologous jugular vein or carotid artery was used as a patch to repair a rat aorta or inferior vena cava. In the aortic environment, patches contained neointimal cells that were CD34/ephrin-B2-dual positive but not CD34/Eph-B4-dual positive; patches expressed ephrin-B2, notch-4, and dll-4 but not Eph-B4 and COUP-TFII. In the venous environment, patches contained neointimal cells that were CD34/Eph-B4-dual positive but not CD34/ephrin-B2-dual positive; patches expressed Eph-B4 and COUP-TFIIbut not ephrin-B2, notch-4, and dll-4. Conclusion: These data show that autologous tissue patches heal by acquisition of the vascular identity determined by the environment into which they are implanted, suggesting some plasticity of adult vascular identity.
  3,164 290 -
Oscillometric pulse wave analysis in newly diagnosed never treated Gujarati hypertensives
Jayesh Dalpatbhai Solanki, Hemant B Mehta, Chinmay J Shah
July-September 2018, 1(2):62-67
DOI:10.4103/VIT.VIT_14_18  
INTRODUCTION: Hypertension is on a high with preponderance of undiagnosed and untreated at-risk individuals. Pulse wave analysis (PWA) provides noninvasive assessment of arterial stiffness and central hemodynamic parameters. It provides more discrete and direct inference about cardiovascular aging that is expected to be exaggerated with systemic hypertension. MATERIALS AND METHODS: A case–control study was conducted in 116 newly diagnosed, never treated, apparently healthy hypertensives and 116 matched nonhypertensive controls. Oscillometric PWA was accomplished by Mobil-o-Graph (IEM, Germany) to derive cardiovascular parameters that were further analyzed. P < 0.05 was considered statistically significant. RESULTS: Cases showed significantly higher brachial arterial parameters (blood pressure [BP], heart rate, and rate pressure product); arterial stiffness (augmentation pressure, augmentation index, pulse wave velocity, total arterial stiffness, and pulse pressure amplification); and central hemodynamics (central BP, cardiac output, and stroke work) than age-, gender-, and height-matched controls. Major study parameters correlated with BP, heart rate, and age, but in multiple regressions, they were independent of most of these parameters. CONCLUSIONS: Oscillometric PWA is feasible in our population. It revealed beyond brachial BP abnormal profile suggestive of early cardiovascular aging in new and never treated hypertensives. It also suggests further work to consolidate and explore these results.
  3,137 316 2
Response of internal mammary artery wall to L-carnitine in patients undergoing coronary artery bypass
Najah R Hadi, Fadhil Al-Amran, Mahamed Al-Turfy, Saad Rasool Shaker, Nasser Ghaly Yousif, Hayder A Al-Aubaidy
July-September 2018, 1(2):56-61
DOI:10.4103/VIT.VIT_11_18  
BACKGROUND: This study attempts to highlight the vasodilatation effects of L-carnitine on the left internal mammary artery (LIMA) in patients undergoing coronary artery bypass graft (CABG) surgery. PATIENTS AND METHODS: A total of 45 male patients (age 55–60 years), and body weight (70–75 kg) were included in this study. Participants were planned to undertake elective CABG surgery, and they were randomly allocated into two study groups as follows: Control group included 15 patients received placebo capsule (lactose capsules), twice daily for 3 successive days before CABG surgery. L-carnitine-treated group included the remaining 30 participants received L-carnitine capsules, 500 mg twice daily for 3 days before CABG surgery. RESULTS: The two groups were comparable according to their age and comorbidities. There was significant increase in the plasma levels of endothelial nitric oxide synthase (eNOS) and matrix Gla-protein (MGP) among the L-carnitine group as compared with the control group (P < 0.001, P = 0.011, respectively). At the same time, tissue eNOS levels and tissue MGP levels were significantly higher (P = 0.078, P < 0.001, respectively) in the L-carnitine group as compared with the control group. Plasma levels of angiotensin II (ANGII) and endothelin-1 (ET-1) levels were significantly lower (P < 0.001) in the L-carnitine group. Tissue levels of ANGII and ET-1 were significantly lower (P = 0.039, P < 0.001, respectively). CONCLUSIONS: We can conclude that L-carnitine has potent vasodilatation effects on LIMA during CABG surgery as evidenced by the increase in plasma and tissue levels of eNOS and MGP, associated with a decrease in plasma and tissue levels of ANGII and ET-1.
  2,964 355 -
Limb salvage following successful infra-inguinal revascularization in diabetic patients
Muhammad Rizwan, Besma Nejim, Hanaa Dakour Aridi, Satinderjit S Locham, Thomas Reifsnyder, Mahmoud B Malas
April-June 2018, 1(1):6-13
DOI:10.4103/VIT.VIT_4_18  
BACKGROUND: Diabetes is a major risk factor for peripheral artery disease (PAD). Infrainguinal bypass surgery (IBS) has been the modality of choice for limb salvage in PAD patients. It is well known that diabetic patients have different disease progression than nondiabetics. Therefore, it is important to assess the outcomes and to determine the efficacy of current surgical practices for limb salvage in the diabetic population. The aim of this study is to evaluate short-term and long-term outcomes after IBS in diabetic patients. MATERIALS AND METHODS: We identified all patients who underwent IBS at our hospital from 2007 to 2014. Explanatory analysis using Pearson's Chi-square test, Fischer's exact test, and Student's t-test was performed. Kaplan–Meier analysis was used to evaluate primary patency, primary-assisted patency, and limb loss. Multivariate Cox regression analysis was implemented to examine loss of patency and amputation after adjusting for patients' demographics and comorbidities. RESULTS: A total of 428 IBSs were performed. Out of those, 264 (62%) were diabetic. Diabetic patients presented on average of 3 years earlier than nondiabetics (66.3 [11.0] vs. 68.9 [11.9], P = 0.03) and had significantly higher comorbidities including dyslipidemia (58% vs. 45% P = 0.01), coronary artery disease (70% vs. 46%, P = 0.01), and chronic kidney disease (20% vs. 2%, P = 0.001). There were more diabetics who presented with critical limb ischemia (CLI) (92% vs. 80%, P < 0.001). There was no difference in all-cause mortality over the study period between the two groups (35% vs. 27%, P = 0.11), but diabetics had three times higher major amputation rates (17% vs. 6%, P = 0.001). After adjusting for potential confounders, the risk of amputation was 2.7 times higher in diabetics (hazard ratio [HR] =2.66, 95% confidence interval [CI]: 1.24–5.72, P = 0.001) with no statistically significant difference in loss of primary patency (HR = 1.23, 95% CI: 0.78–1.94, P = 0.37) or primary-assisted patency (HR = 0.98, 95% CI: 0.58–1.64, P = 0.94). CONCLUSIONS: In this study, we found no significant difference in graft patency between diabetic and nondiabetic patients; however, limb loss was almost four folds higher in diabetics with CLI after IBS. This suggests that additional factors after revascularization play an important role in limb salvage in diabetics. Further prospective study in a larger cohort of patients is suggested to evaluate the outcomes of IBS and endovascular therapy in diabetic patients.
  2,777 307 -
NEW TECHNOLOGY
Severe vertebral artery stenosis treated by directional atherectomy
Yongquan Gu, Jianming Guo, Lianrui Guo, Shijun Cui, Hanaa-Dakour Aridi, Mahmoud B Malas, Zhu Tong, Yixia Qi, Lixing Qi
October-December 2018, 1(3):110-114
DOI:10.4103/VIT.VIT_17_18  
We report the outcomes of directional atherectomy using a distal protective device and drug-coated balloon angioplasty in four patients with severe atherosclerotic vertebral artery stenosis. All cases were clinically successful with complete resolution of the symptoms. Immediate and postoperative results showed a good technical success. These results suggest that vertebral artery stenosis treated with directional atherectomy is technically feasible and may be a safe and effective option when performed by experienced endovascular surgeons.
  2,786 297 -
REVIEW ARTICLE
Exercise oximetry in arterial claudication
Pierre Abraham, Tianyu Ma, Huifei Chen, Lianrui Guo, Yongquan Gu, Samir Henni
July-September 2018, 1(2):80-86
DOI:10.4103/VIT.VIT_15_18  
Transcutaneous oxygen pressure measurement (TcPO2) is well known as a useful tool for the evaluation of critical limb ischemia, but it is rarely used during exercise (Ex-TcPO2). We have used exercise oximetry, in Angers, as a noninvasive vascular investigation for about >15 years to detect regional blood flow impairment at the proximal and distal levels simultaneously and on both sides. The use of a chest electrode is required to calculate the Delta from rest of oxygen pressure index (DROP) and account for eventual systemic exercise-induced hypoxemia. The DROP index that we proposed in our first publication in 2003, because of its mathematical formula, is independent of the absolute oxygen pressure starting values which result in improved reliability of Ex-TcPO2 as compared to the regional perfusion index. The present review is of specific interest at a time when the technique is rapidly spreading in France and Abroad.
  2,800 252 -
ORIGINAL ARTICLES
Comparison of therapeutic effects between open surgery and endovascular therapy for juxtarenal aortic occlusion
Yongquan Gu, Lixing Qi, Alan Dardik, Xixiang Gao, Lianrui Guo, Zhu Tong, Jianming Guo, Jian Zhang, Zhonghao Wang
July-September 2018, 1(2):74-79
DOI:10.4103/VIT.VIT_16_18  
OBJECTIVE: To compare the effectiveness of surgical bypass and endovascular therapy for juxtarenal abdominal aortic occlusion. METHODS: Data of 37 patients treated with open arterial bypass surgery or endovascular therapy for juxtarenal abdominal aortic occlusion in the last 10 years were retrospectively analyzed. RESULTS: Of the 37 cases, 32 were male and five were female; the mean age was 58.5 years; the mean disease history was 8.2 months. Open surgery was performed in 18 cases and endovascular treatment was done in 19 cases. No significant differences in either technical success rate or perioperative symptom improvement rate were found between the open surgery and endovascular therapy groups. There w as much more blood loss, hospital stay time, and fewer hospitalization expenses in the open group than the endo group. In the open group, the mean follow-up time was 60.5 months and graft patency rate was 94.4%; in the endo group, the mean follow-up was 52.5 months but the patency rate was 82.4% (P = 0.009). CONCLUSIONS: Both open surgery and endovascular treatment are effective for juxtarenal aortic occlusion. In comparison, open surgery has lower cost with better long-term eff icacy, while endovascular therapy has less invasiveness with faster postoperative recovery. O perative approach should be made according to the patient's clinical conditions.
  2,759 277 -
REVIEW ARTICLE
Pathophysiological mechanisms of chronic venous disease and their role in C0s clinical class
Andrew Nicolaides, Eliete Bouskela
October-December 2018, 1(3):103-109
DOI:10.4103/VIT.VIT_2_19  
The aim of this review is to provide a clear understanding of the pathophysiological mechanisms of chronic venous disease (CVD) at different clinical stages and the possible role of these mechanisms in the development of symptoms in C0s clinical class of the Clinical, Etiologic, Anatomic, and Pathophysiologic classification, which consists of symptomatic patients without any visible or palpable signs of venous disease. The prevalence of C0s class in several epidemiological studies varies between 13% and 23% of the general population. Wall remodeling and valve destruction due to white cell endothelial interaction is the main cause of primary varicose veins, while deep vein thrombosis produces secondary changes leading to the postthrombotic syndrome. The underlying mechanism of the skin changes and ulceration is venous hypertension, which is transmitted to the skin microcirculation. Over the last 10 years, an improved videocapillaroscopic technique, the orthogonal polarization spectral imaging technique demonstrated that quantitative measurements in the skin microcirculation are progressively altered from C1 to C6 patients and that values in CVD patients are significantly different from healthy individuals (P < 0.05): capillary diameter increases and capillary morphology worsens from C2 to C5; diameter of the dermal papilla and diameter of the capillary bulk increase from C3 to C5; and functional capillary density (FCD) decreases from C4 to C5. In addition, significant changes have been shown between C0a and C0s patients despite the presence of normal conventional duplex scans in the latter: a decrease of FCD and an increase in the diameter of the dermal papilla. Functional abnormalities found to be present in C0s patients by recent studies include increased compliance of the venous wall (hypotonic phlebopathy), dilatation of deep veins in the calf producing an abnormally increased venous volume, reduction in emptying of venous reservoir, reduction in the venoarteriolar response on standing, and blood reflux in small venules despite a normal conventional duplex scan. However, most of the studies are small, and their findings need to be confirmed by larger series. It remains to be seen whether functional changes and microcirculatory changes respond to venoactive medications in parallel to the relief of symptoms.
  2,710 305 3
ORIGINAL ARTICLES
Race and outcomes of lower extremity revascularization for critical limb ischemia
Karen Massada, Muhammad Rizwan, Hanaa Dakour Aridi, Mohammed Hasan, Isibor Arhuidese, Mahmoud B Malas
April-June 2018, 1(1):24-29
DOI:10.4103/VIT.VIT_8_18  
INTRODUCTION: Studies have shown poor outcomes following infra-inguinal bypass in African-American patients compared with Caucasians. The aim of this study was to investigate the racial disparity in a cohort of patients who underwent infra-inguinal bypass surgery at our institute. METHODS: We retrospectively reviewed data of all patients who underwent infra-inguinal bypass performed with autogenous vein grafts for symptomatic peripheral artery disease from 2007–2014 at a single tertiary care institution. Univariate (Chi-square test and Student's t-test) and multivariable analyses (logistic and Cox regression) were used to evaluate the association between race and the outcomes of mortality, primary and primary-assisted patency, and limb loss following infra-inguinal bypass. RESULTS: The study included 412 autogenous bypass grafts, of which 312 (76%) were performed in Caucasians and 100 (24%) in African-Americans. African-American patients had significantly higher comorbidities including diabetes (74% vs. 57%, P = 0.002) and chronic kidney disease on dialysis (22% vs. 10%, P = 0.002) as compared with Caucasians. The majority of patients in both groups underwent bypass for critical limb ischemia (88% vs. 87%, P = 0.71). Mean follow-up time was 1.8 ± 1.8 years. The rates of major amputation were not significantly different between two groups (17% vs. 10%, P = 0.07). Moreover, no significant differences in primary and primary assisted were seen between African-Americans and Caucasians (hazard ratio [HR] [95% confidence interval [CI]: 0.90 [0.56–1.44], P = 0.66 and 1.21 [0.72–2.03], P = 0.46), respectively. Hyperlipidemia was shown to be significantly associated with primary-assisted patency, while diabetes was a significant risk factor for limb loss [HR (95% CI): 2.73 (1.26–5.93), P = 0.01). CONCLUSION: In this study, there were no significant differences in bypass patency and limb salvage between African-Americans and Caucasians following infra-inguinal bypass over 5-year follow-up. These findings suggest that the outcomes of infra-inguinal bypass can be optimized in African-American patients with the use of autogenous vein conduits and comprehensive medical management including the control of diabetes and hyperlipidemia.
  2,712 254 -
Sleep disruption aggravates disturbed glucoregulatory and systemic inflammation among diabetic foot patients
Chunting Ye, Hui Li, Zhu Tong, Lixing Qi, Lianrui Guo
April-June 2018, 1(1):30-34
DOI:10.4103/VIT.VIT_2_18  
CONTEXT: Sleep disturbance and proinflammatory markers were reported to link to the development of type 2 diabetes mellitus and glucose homeostasis. METHODS: A clinical laboratory–based analysis was performed on 14 normal volunteers, 11 diabetic patients and 16 non-diabetic patients form department of vascular surgery conducted between January 2013 and March 2013. Continuous polysomnographic monitoring was performed on 2 nights in the intensive care unit (IUC). Blood glucose level was controlled by insulin infusion. Concentrations of IL-6 and CRP levels were determined by enzyme-linked immunoassays. OBJECTIVE: To raise awareness of risk factors among postsurgery type 2 diabetes with foot ulcers. DESIGN: A clinical laboratory-based analysis was performed on 14 normal volunteers, 11 diabetic patients, and 16 nondiabetic patients from Department of Vascular Surgery conducted between January 2013 and March 2013. SETTING: This trial was admitted to Siping hospital affiliated to China Medical University, China. PATIENTS: Twenty-seven patients were postthrombolytic therapy and 14 healthy controls. INTERVENTIONS: Continuous polysomnographic monitoring was performed on 2 nights in the Intensive Care Unit (ICU). Blood glucose level was controlled by insulin infusion. Concentrations of interleukin-6 (IL-6) and C-reactive protein (CRP) levels were determined by enzyme-linked immunoassays. MAIN OUTCOME MEASURE: Changes in exogenous insulin requirements, while IL-6 and CRP levels. RESULTS: Insulin requirements on admission in ICU 48-h treatment increased 21.2% in diabetic patients compared to 24-h postsurgery. All postsurgical patients elevated IL-6 and CRP levels compared to normal individuals in the morning after 24 h and 48 h of sleep restriction. Fasting concentrations of IL-6 were distinctly increased 23.6% and 42.9%, respectively, after 24 h and 48 h of sleep restriction in diabetic patients compared to normal individuals and 18.5% and 21.8%, respectively, compared to nondiabetic patients. CRP levels are similar to IL-6 levels among these partners. CONCLUSIONS: Our study elucidated that sleep disruption aggravates disturbed glucoregulatory and systemic inflammation among postsurgical diabetic patients, which might contribute to understand these disorders for diabetic patients in immunological pathways.
  2,610 256 -
A retrospective analysis of eosinophilic disorder on poststroke pneumonia
Xin Huo, Wanchen Shi, Tianqi Zhang, Libin Guo, Ying Liu
October-December 2018, 1(3):98-102
DOI:10.4103/VIT.VIT_3_19  
OBJECTIVE: The objective of the study was to evaluate the role of eosinophil on the outcome and prognosis in stroke patients with pneumonia. PATIENTS AND METHODS: The study included 526 patients with ischemic stroke; the patients were divided into two groups according to whether the patients were complicated with pneumonia or not. All patients were supervised by the National Institutes of Health Stroke Scale (NIHSS) score in 2 weeks. RESULTS: Stroke patients without pneumonia were observed a higher eosinophil count and lower platelet distribution width (PDW) compared to the patients with pneumonia (P < 0.05). Eosinophil counts continued to decrease in patients with pneumonia along with an increasing NIHSS score in 2 weeks. Logistic regression identified dysphagia, eosinophil count, and PDW as predictors of NIHSS scores in poststroke patients with pneumonia. CONCLUSIONS: Our data suggested that eosinophil counts might have a significant role on outcomes in poststroke patients with pneumonia. The results underscored that the interaction between eosinophils and platelets might be a treatment target to improve the outcomes in stroke patients.
  2,626 228 -
Incidence and outcomes of infected peripheral pseudoaneurysms in drug abusers
Rami Srouji, Hanaa Dakour-Aridi, Satinderjit Locham, Besma Nejim, Mahmoud B Malas
April-June 2018, 1(1):35-39
DOI:10.4103/VIT.VIT_3_18  
BACKGROUND: Intravenous drug abusers (IVDA) are at an increased risk of developing infected peripheral pseudoaneurysms. The aim of this study is to describe a group of IVDA patients who present with infected peripheral pseudoaneurysms and to evaluate the outcomes of vascular surgery reconstruction in this population. MATERIALS AND METHODS: A retrospective study of all IVDA patients presenting with peripheral pseudoaneurysms between 2009 and 2015 in the premier healthcare vascular surgery database 2009–2015 were identified. Patients' demographics, comorbidities, along with the vascular procedures performed, and in-hospital complications were reported. RESULTS: Out of 2012 vascular surgery patients known to be opioid abusers, 71 (3.5%) presented with infected peripheral pseudoaneurysms (mean age: 44.8 years, standard deviation: 15.0). The majority of these patients were Caucasians or Whites (64.8%) and underwent resection of the upper or lower limb arteries (29.7%), clipping of aneurysm (21.9%), or bypass procedures (9.4%). Two patients (3.1%) underwent primary major amputation. In-hospital mortality was observed in 1.4% of patients, hemorrhage/shock in 12.7% and cardiac arrhythmias in 7%. Four patients (5.6%) underwent secondary major amputation during the same hospitalization. Median length of hospital stay was 8 days. Around 24% of these patients were discharged to a skilled nursing facility or a rehabilitation center. The median cost of hospitalization for these patients was 21,807 (USD) with a median fixed and variable cost of 10,392 and 9356 (USD), respectively. CONCLUSION: IVDA patients with infected pseudoaneurysms are at high risk for postoperative complications, major morbidity, extended length of stay, and nonhome discharge destination which poses a huge medical, social, and economic burden.
  2,584 239 -
Hyperthermic isolated limb perfusion: Does it still have a role?
Jessica Reid, Michael Rooke, Colin Hawksmith, Craig Jurisevic, Michael P Brown, Susan J Neuhaus
October-December 2018, 1(3):87-92
DOI:10.4103/VIT.VIT_18_18  
BACKGROUND: Hyperthermic-isolated limb perfusion (ILP) with melphalan is an established modality for the treatment of irresectable malignancy of an extremity, including melanoma. ILP isolates the affected limb from the systemic circulation, using an extracorporeal bypass circuit, and administering high-dose intra-arterial chemotherapy. While this technique remains the “gold standard” and is practiced at high-volume surgical oncology centers worldwide, as new systemic treatments have become available, it is timely to review the current place of regional chemotherapy. PATIENTS AND METHODS: Twenty-six ILPs were performed between 2006 and 2013 at a single center. Patient's parameters, clinical outcomes, and survival were evaluated. Twenty procedures were for melanoma, five for sarcoma, and one for extensive basal cell carcinoma (BCC). RESULTS: ILP was well tolerated with few intraoperative or postoperative complications. Within the melanoma group, limb toxicities were low with one Grade III and no severe (Wieberdink IV+) toxicities. Limb salvage was achieved in 2/5 sarcoma patients. At 6 weeks' postprocedure, 13 melanomas, two sarcomas, and the BCC patient reported a complete response (16/26). However, 5 years after the last procedure, and a median follow-up of 23 months, the majority of melanoma and all sarcoma patients went on to develop local recurrence or metastatic disease. CONCLUSIONS: ILP is a useful technique to provide high-dose chemotherapy to refractory limb malignancy to provide effective palliation, delay progression, or even obtain cure. However, as new effective systemic therapies emerge, the role of isolated regional chemotherapy (ILP and isolated limb infusion) needs to be reevaluated.
  2,576 236 -
ORIGINAL ARTICLE
Mortality risk stratification in patients with asymptomatic carotid stenosis
A Giannopoulos, S Kakkos, MB Griffin, G Geroulakos, D Tsalikakis, Andrew Nicolaides
April-June 2019, 2(2):25-32
DOI:10.4103/VIT.VIT_10_19  
AIMS: The aim of this analysis was to (a) determine the long-term 5-year all-cause and cardiovascular (CV) mortality in patients with asymptomatic internal carotid artery stenosis (ACS), (b) identify risk factors that could be used in mortality risk stratification, and (c) develop a model for predicting a patient's risk of CV death within 5 years. METHODS: This was a multicenter natural history study involving 1121 patients with ACS undergoing medical intervention alone. Proportional-hazards models were used to calculate all-cause and CV mortality using clinical and plaque texture features. RESULTS: Totally 1121 patients with 50%–99% ICA stenosis (European Carotid Surgery Trial criteria) from the Asymptomatic Carotid Stenosis and Risk of Stroke study were included in this analysis for mortality. Mean follow-up was 48 months (range, 6–96 months). There were 213 (19%) deaths during follow-up. Average annual all-cause mortality was 4.6%. About 68.1% of all deaths were due to CV causes. Independent predictors of all-cause mortality were age, male gender, carotid stenosis >80% (NASCET criteria), diabetes, cardiac failure, left ventricular hypertrophy (LVH) on electrocardiogram (ECG), smoking, absence of antiplatelet therapy, and history of vertebrobasilar symptoms. It was also shown that age, male gender, diabetes, fibrinogen >3.6 g/L, carotid stenosis >80% (NASCET criteria), cardiac failure, absence of antiplatelet therapy, and LVH on ECG were independent risk factors for CV mortality. Receiver operating characteristic curves for the above models were 0.709 (95% confidence interval [CI], 0.659–0.754) and 0.701 (95% CI, 0.656–0.746), respectively. The CV mortality prediction model could identify several subgroups of asymptomatic patients with different risk. The highest 90%–100% predicted 5-year CV mortality carried 25 times the risk of the low-risk subgroup in which the 5-year predicted CV mortality was 4%. CONCLUSION: Mortality risk can be taken into consideration in clinical practice, in order to identify patients with ACS who are unlikely to benefit from carotid endarterectomy. The majority of patients with ACS have a very high risk of myocardial infarction and should not be denied aggressive risk factor modification or a full cardiac investigation according to the current guidelines.
  2,527 236 4
ORIGINAL ARTICLES
Ultrasound-guided transbrachial arterial access: A safe approach for hemodialysis arteriovenous fistula intervention
Nwe Ni Aung, Jialing Lim, Julia Xue, Pei Ho
January-March 2019, 2(1):8-14
DOI:10.4103/VIT.VIT_7_19  
CONTEXT: Endovascular interventions for hemodialysis arteriovenous fistula (AVF) can be performed through transfistula, transradial, and transbrachial artery access (TBA), but many interventionists consider TBA a risky approach and thus avoid using it. AIMS: We conducted a retrospective review to report the safety and applications of TBA for AVF interventions. SETTINGS AND DESIGN: Consecutive endovascular procedures for AVFs with TBA applied during a 2-year period were retrospectively reviewed. SUBJECTS AND METHODS: All brachial artery cannulations were performed under ultrasound guidance, either for fistulogram (20G cannula) only or for both angiogram and therapeutic purposes (4–6 Fr sheath). Demographics, comorbidities, antiplatelet and anticoagulant usage, indications of procedure, lesion sites, treatment outcome, and complication were reported. STATISTICAL ANALYSIS USED: Excel version 2010. RESULTS: One hundred AVF procedures that adopted TBA were performed for 73 patients during the study period (4 diagnostic fistulogram and 96 therapeutic interventions). Indications were dysfunctional AVF (n = 82), acute fistula thrombosis (n = 9), failure-to-mature (n = 8), and steal syndrome (n = 1). In 61 and 5 procedures, the patients were on long-term antiplatelet and anticoagulant agents, respectively. In 69 procedures, more than one lesion were identified in the AVF circuit. Stenosis over the anastomosis, juxta-anastomosis, and cannulation zone was found in 40.6%, 74%, and 67.7% of the AVFs, respectively. Thirty-two procedures had transbrachial 20G cannula inserted and 68 procedures had 4–6 Fr introducer sheath inserted. Technical success of the therapeutic interventions was 98.9%. Two patients developed limited hematoma at TBA site after the procedure and resolved with conservative management. No major complication (hemorrhage, nerve injury, pseudoaneurysm, and dissection) was noted from all the TBA procedures. CONCLUSIONS: TBA is a safe approach for AVF endovascular therapy.
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Close association between carotid and coronary atherosclerosis analyzed through SYNTAX score
P Levantino, G Polizzi, S Evola, G Leone, G Evola, G Novo, S Novo
January-March 2019, 2(1):1-7
DOI:10.4103/VIT.VIT_5_19  
AIM: This study analyzed the association between carotid and coronary atherosclerosis, particularly in terms of the severity as well as the extension of the disease. MATERIALS AND METHODS: We have recruited a consecutive series of 478 patients (admitted to the Cardiology Unit of University Hospital Paolo Giaccone during 2004–2014). These patients underwent both carotid Doppler ultrasound and coronary angiography. Sex, age, and traditional cardiovascular risk factors were considered. The SYNTAX score was used to grade the complexity of coronary disease. RESULTS: The present study revealed a clear association between carotid atherosclerosis and coronary disease: 68.2% of the examined population showed atherosclerosis in both carotid and coronary arteries. The absence of carotid atherosclerosis was predominantly associated with angiographically normal coronary arteries (37.6%) rather than a single-vessel disease (22.8%), a two-vessel disease (21.8%), or a three-vessel disease (17.8%). When carotid atherosclerosis was present, a normal coronary angiography was uncommon (13.5%), while the detection of a single-vessel disease was more frequent (17.2%), a two-vessel disease was even more frequent (27.6%), and the highest rate described was related to a three-vessel coronary artery disease (CAD) (41.6%). The thickness of the carotid lesion was directly proportional to the number of diseased coronary vessels, and it was also related to the severity of coronary involvement measured by the SYNTAX score. CONCLUSIONS: This study has shown a strong correlation between carotid atherosclerosis and CAD, in terms of extension, and most importantly, severity. It is fundamental to consider a systemic approach to atherosclerosis to obtain an adequate stratification of patients with cardiovascular risk factors and an appropriate therapeutic management and reduce the incidence of adverse events, improving the quality of life and prolonging survival.
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Near-infrared spectroscopy of the thigh fails to discriminate cyclists with arterial endofibrosis from normal asymptomatic athletes
T Julienne, M Ammi, J Hersant, S Henni, P Abraham
October-December 2018, 1(3):93-97
DOI:10.4103/VIT.VIT_1_19  
BACKGROUND: This study is to assess the applicability and performance of the near-infrared spectroscopy (NIRS) in the diagnosis of exercise-induced arterial endofibrosis (EIAE). METHODS: NIRS was measured on each thigh, in 12 highly trained asymptomatic cyclists (controls) and 14 EIAE patients highly trained competition cyclists. All patients had an incremental bicycle stress test until exhaustion or symptom limitation. Results are presented as median (25°; 75° centiles) and between groups difference calculated with Mann–Whitney test. RESULTS: Six of the NIRS recordings technically failed: three in controls and three in EIAE patients due to probe disconnection. In the remaining nine controls and 11 EIAE patients, no difference was found at peak exercise for tissue saturation index (−2.0% [−8.5; 2.1] vs. −4.0% [−5.9; 5.5]; P = 0.710) or for half-time recovery (42.0 s [24.9; 105.0] vs. 42.0 s [33.0; 112.7]; P = 0.905) between EIAE and controls, respectively. CONCLUSION: NIRS, when available, does not satisfactorily discriminate patients with EIAE from asymptomatic healthy athletes.
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CASE REPORT
Anterior spinal cord infarction as a complication of bronchial artery embolization in the management of recurrent hemoptysis
Ramandeep Singh, Siddharth Prakash, Paramdeep Singh, Rupinderjeet Kaur, Rubal Rai
April-June 2019, 2(2):51-53
DOI:10.4103/VIT.VIT_12_19  
Bronchial artery embolization (BAE) is an established minimally invasive approach for the treatment of massive or recurrent hemoptysis. There are several minor complications associated with the procedure. A rare complication of the procedure is spinal cord infarction due to embolization of anterior spinal artery. A 48-year-old male patient of old pulmonary tuberculosis presented with fibrocalcified lesions in the right upper lobe on chest X-ray and recurrent hemoptysis. Angiography revealed bleeding from a branch of single right intercostobranchial trunk. The day following the procedure, the patient complained of weakness and pain in lower limbs. Magnetic resonance imaging dorsolumbar spine revealed acute spinal cord infarct from D2 to D5 vertebral levels. This case demonstrates that spinal cord ischemia may occur during BAE, despite all the precautionary measures.
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ORIGINAL ARTICLES
Retrospective study of hepatic encephalopathy by different transjugular intrahepatic portosystemic shunt ways in portal hypertension
Xin Huo, Xiao Wen Cui, Min Wang, Chong Jing, Yue Wu, Xin Ming Yu, Hui Zhou, Wen-Peng Li, Xue-Chao Cai, Guan-Zhou Zhou, Yong-Jie Zhang
January-March 2019, 2(1):15-18
DOI:10.4103/VIT.VIT_6_19  
OBJECTIVE: The objective of the study was to evaluate the effectiveness and safety of the use of different shunting ways in patients with liver cirrhosis undergoing transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS: We analyzed the data of 36 patients with liver cirrhosis who received de novo TIPS implantation. Sixteen patients had elective TIPS by shunting the blood to the left downstream veins and 20 to the right ones. All patients were followed up for 2 years. We assessed hepatic encephalopathy (HE), rebleeding, and survival rate in all patients post-TIPS. RESULTS: Under our surgical procedure, more post-TIPS HE was observed in the TIPS-left group, whereas rebleeding was detected in the TIPS-right group (P < 0.05). CONCLUSIONS: The decision regarding TIPS placement way for portal hypertension patients needs individualization to allow its safe use, with concomitant improvement in perioperative morbidity.
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