Bilateral pulmonary artery stenosis with pulmonary hypertension due to Takayasu’s arteritis, examined using quantitative flow ratio during revascularisation

Therapeutic effect evaluation is based on morphology performed by angiography conventionally. QFR is a new angiography-based tool for vascular assessment of functional severity. We report the first QFR examination in the field of Takayasu's arteritis patient with pulmonary artery stenosis and pulmonary arterial hypertension. It seems simple and practicable during off-line pulmonary artery intervention assessment.

A Novel Endoscopic Ultrasonography Imaging Technique for Depicting Microcirculation in Pancreatobiliary Lesions without the Need for Contrast-Enhancement: A Prospective Exploratory Study

Detective flow imaging endoscopic ultrasonography (DFI-EUS) provides a new method to image and detect fine vessels and low-velocity blood flow without using ultrasound contrast agents. The aim of this study was to evaluate the utility of DFI-EUS for pancreatobiliary lesions and lymph nodes. Between January 2019 and January 2020, 53 patients who underwent DFI-EUS, e-FLOW EUS, and contrast-enhanced EUS were enrolled. The ability of DFI-EUS and e-FLOW EUS to detect vessels was compared with that of contrast-enhanced EUS. This article describes the DFI technique along with our first experience of its use for vascular assessment of pancreatobiliary lesions. Vessels were imaged in 34 pancreatic solid lesions, eight intraductal papillary mucinous neoplasms (IPMNs), seven gall bladder lesions, and four swollen lymph nodes. DFI-EUS (91%) was significantly superior to e-FLOW EUS (53%) with respect to detection of vessels (p < 0.001) and for discrimination of mural nodules from mucous clots in IPMN and gallbladder lesions from sludge (p = 0.046). Thus, DFI-EUS has the potential to become an essential tool for diagnosis and vascular assessment of various diseases.

Comparison Between Time-Resolved Magnetic Resonance Angiography and Diagnostic Digital Subtraction Angiography in the Vascular Assessment of Nonspecific Aorto-Arteritis Patients: A Prospective Study

Purpose: Nonspecific aortoarteritis (NSAA) is a chronic inflammatory vasculitis involving aorta and its branches. We conducted a study prospectively to compare time resolved magnetic resonance angiography (MRA) with diagnostic digital subtraction angiography (DSA) for the vascular assessment in the patients of NSAA. Materials and Methods: Seventeen patients of NSAA were recruited in the study over the period of 3 years. Contrast enhanced MRA using Time-resolved angiography With Interleaved Stochastic Trajectories (TWIST) sequence and diagnostic DSA were performed in these 17 patients. Results: The majority of the patients were young (median age was 25 years, range 8 to 46 years) and 11 patients were females. Erythrocyte sedimentation rate (ESR) was elevated in 9 patients and C-reactive protein (CRP) was elevated in 6 patients. Most commonly involved vessels in our patients were right renal artery (14 patients), abdominal aorta (12 patients) and left renal artery (11 patients). Left and right subclavian arteres were involved in 10 and 6 patients respectively. The sensitivity and specificity of time-resolved MRA using TWIST sequence is 100% as compared to DSA in the assessment of major vessels such as aorta, arch vessels, celiac artery and superior mesenteric artery. However, the sensitivity and specificity of time resolved MRA in the evaluation of renal arteries and vertebral arteries were 100%, 71.4% and 85.7%, 33.3% respectively. No significant association of MRI contrast enhancement with erythrocyte sedimentation rate (p = 1.00) and C-reactive protein (p = 0.600). Conclusion: Time resolved MRA images obtained using TWIST sequence were as qualitative as DSA images and can noninvasively evaluate the vascular involvement in NSAA patients.

Standard exercise stress testing attenuates peripheral microvascular function in patients with suspected coronary microvascular dysfunction

Background The effect of exercise on the microvasculature of patients with suspected coronary microvascular dysfunction (CMD), assessed by reactive hyperemia peripheral arterial tonometry (RH-PAT; EndoPAT), is unknown. The present study aimed to determine if standard clinical exercise stress testing (GXT) affected peripheral microvascular function, as determined by the reactive hyperemia index (RHI and LnRHI), in patients with suspected CMD. Methods In a cross-sectional study, patients (n = 76) were grouped based on whether the GXT was performed; 1) prior to (exercisers; n = 30), or 2) after the vascular assessment (non-exercisers; n = 46). Patients with an adenosine index of microvascular resistance > 25, adenosine coronary flow reserve (CFR) < 2.0, and/or acetylcholine CFR < 1.5 were considered to have CMD (n = 42). RHI and LnRHI quantified finger pulse amplitude hyperemia following 5 min of forearm ischemia. Results LnRHI was lower in patients with CMD compared to patients without CMD, while LnRHI was also lower in exercisers compared to non-exercisers (LnRHI: CMD Non-Exercisers: 0.63 ± 0.25; CMD Exercisers: 0.54 ± 0.19; No CMD Non-Exercisers: 0.85 ± 0.23; No CMD Exercisers: 0.63 ± 0.26; Condition and Exercise Main Effects: Both P < 0.01). In patients who did not exercise prior to the vascular assessment, the receiver operating characteristic curve (ROC) for LnRHI to predict CMD was 0.76 (95% CI: 0.62–0.91; P < 0.01). However, in patients who performed exercise prior to the vascular assessment, the ROC for LnRHI to predict CMD was 0.60 (95% CI: 0.40–0.81; P = 0.34). Conclusions CMD is associated with impaired peripheral microvascular function and preceding acute exercise is associated with further reductions of LnRHI. Further, acute exercise abolished the capacity for RH-PAT to predict the presence of CMD in patients with chest pain and non-obstructive coronary arteries. RH-PAT measurements in patients with suspected CMD should not be conducted after exercise has been performed.

The management of acute knee dislocations: A global survey of orthopaedic surgeons’ strategies

Purpose: Great variety and controversies surround the management strategies of acute multiligament knee injuries (aMKLIs) and no established guidelines exist for resource-limited practices. The aim of this study was to compare the management approach of acute knee dislocations (AKDs) by orthopedic surgeons from nations with different economic status. Methods: This descriptive cross-sectional scenario-based survey compares different management strategies for aMLKIs of surgeons in developed economic nations (DEN) and emerging markets and developing nations (EMDN). The main areas of focus were operative versus non-operative management, timing and staging of surgery, graft choice and vascular assessment strategies. The members of the Societe Internationale de Chirurgie Orthopedique et de Traumatologie (SICOT) were approached to participate and information was collected regarding their demographics, experience, hospital setting and management strategies of aMLKIs. These were analyzed after categorizing participants into DEN and EMDN based on the gross domestic product (GDP) per capita. Results: One-hundred and thirty-eight orthopedic surgeons from 47 countries participated in this study, 67 from DEN and 71 (51.4%) from EMDN. DEN surgeons had more years of experience and were older (p < 0.05). Surgeons from EMDN mostly worked in public sector hospitals, were general orthopedic surgeons and treated patients from a low-income background. They preferred conservative management and delayed reconstruction with autograft (p < 0.05) if surgery was necessary. Surgeons from DEN favored early, single stage arthroscopic ligament reconstruction. Selective Computerized Tomography Angiography (CTA) was the most preferred choice of arterial examination for both groups. Significantly more EMDN surgeons preferred clinical examination (p < 0.05) and duplex doppler scanning (p < 0.05) compared to DEN surgeons. More surgeons from EMDN did not have access to a physiotherapist for their patients. Conclusions: Treatment of aMLKIs vary significantly based on the economic status of the country. Surgeons from DEN prefer early, single stage arthroscopic ligament reconstruction, while conservative management is favored in EMDN. Ligament surgery in EMDN is often delayed and staged. EMDN respondents utilize duplex doppler scanning and clinical examination more readily in their vascular assessment of aMLKIs. These findings highlight very distinct approaches to MLKIs in low-resource settings which are often neglected when guidelines are generated.

Vascular Assessment in Patients With a Lower Limb Wound: A Correlational Study of Photoplethysmography and Laser Doppler Flowmetry Toe Pressure Techniques

Background: Vascular assessment of the lower limbs is essential in patients with diabetes. In the presence of noncompressible arteries, the ankle brachial index (ABI) can either be inconclusive or provide false-positive results. Toe pressure measurement has been suggested as an alternative as a noninvasive method for detecting peripheral arterial disease (PAD). Toe pressure measurement can be performed either by photoplethysmography (PPG) or by Laser Doppler flowmetry (LDF). The aim of this study was to determine correlations between the two techniques in order to promote the use of PPG in clinical practice. Methods: This was a prospective correlational study of 108 consecutive recruited adult patients, with and without diabetes, with at least one lower limb wound from a University-affiliated hospital wound care clinic. Toe pressure measurements were both performed with PPG and LDF devices. Results: Mean toe pressure values for PPG and LDF were, respectively, 83.7 (SD 35.4) and 79.5 (SD 32.0) mmHg (with a paired t-test 3.969, P < 0.01). In patients with at least one lower limb wound, a strong linear relation was found between PPG and LDF toe pressure techniques with a Pearson’s r correlation coefficient of 0.920 ( P < 0.001). Conclusions: PPG and LDF toe pressure techniques are equivalent in patients with at least one lower limb wound, irrespective of the presence of diabetes. Therefore, in the presence of an ABI with inconclusive results, such as in a patient with noncompressible vessels, both toe pressure techniques can be used for assessing the vascular supply of the lower limb with a wound.