Cerebral hemodynamic effects of early blood pressure lowering after TIA and stroke in patients with carotid stenosis

Background: Effects of early blood pressure (BP) lowering on cerebral perfusion in patients with moderate/severe occlusive carotid disease after transient ischemic attack (TIA) and non-disabling stroke are uncertain. Aims: We aimed to evaluate the changes in transcranial Doppler (TCD) indices in patients undergoing blood pressure lowering soon after TIA/non-disabling stroke. Methods: Consecutive eligible patients (1 November 2011 to 30 October 2018) attending a rapid-access clinic with TIA/non-disabling stroke underwent telemetric home blood pressure monitoring (HBPM) for 1 month and middle cerebral artery velocities measurements ipsilateral to carotid stenosis on TCD ultrasound in the acute setting and at 1 month. Hypertensive patients (HBPM ⩾ 135/85) underwent intensive BP-lowering guided by HBPM unless they had bilateral severe occlusive disease (⩾ 70%). Changes in BP and TCD parameters were compared in patients with extracranial moderate/severe carotid stenosis (between 50% and occlusion) versus those with no or mild (< 50%) stenosis. Results: Of 764 patients with repeated TCD measures, 42 had moderate/severe extracranial carotid stenosis without bilateral severe occlusive disease. HBPM was reduced from baseline to 1 month in hypertensive patients both with versus without moderate/severe carotid stenosis (−12.44/15.99 vs −13.2/12.2 mmHg, respectively, p-difference = 0.82), and changes in TCD velocities (4.69/14.94 vs 2.69/13.86 cm/s, respectively, p-difference = 0.52 for peak systolic velocity and 0.33/7.06 vs 1.75/6.84 cm/s, p-difference = 0.34 for end-diastolic velocity) were also similar, with no evidence of greater hemodynamic compromise in patients with stenosis/occlusion. Conclusion: There was no evidence of worsening of TCD hemodynamic indices in patients with moderate/severe occlusive carotid disease treated with BP-lowering soon after TIA/non-disabling stroke, suggesting that antihypertensive treatment in this group of patients is safe in the acute setting of TIA clinics.

Estimation of haemodynamic changes in varicocele testis and results after microsurgical sub-inguinal varicocelectomy

Introduction: Varicocele is among the most frequently encountered, surgically correctable causes of male infertility. Since varicocele is a primary abnormality of testicular vessels, a thorough understanding of haemodynamic changes in the microcirculation of varicocele testis is needed. Objectives: To estimate changes in the microcirculation of varicocele testis and correlate them with symptomatic and semen parameters changes before and after varicocelectomy. Material and methods: This prospective, observational study includes 47 patients of age group 18–40 years who underwent microsurgical varicocelectomy during June 2016 to April 2018 at a tertiary medical institute. Testicular haemodynamic was evaluated using a colour spectral doppler study (PSV-Peak systolic velocity/ESV-End diastolic velocity/RI-Resistive index/PI-Pulsatility index). Semen analysis parameters and testicular blood flow were compared with pre-operative values. Results: RI in the capsular artery of varicocele affected testis, which was 0.61 ± 0.11 (mean ± SD), significantly reduced to 0.56 ± 0.09 (mean ± SD) in post-operative follow-up, indicating improved perfusion. Pre-operative sperm density was noted to be 15.94 ± 7.88 (mean ± SD), which improved to 28.41 ± 10.99, Progressive sperm motility from 33.81 ± 10.88 to 38.32 ± 9.21 and morphology from 36.13 ± 10.68 to 41.43 ± 9.29 on 6-month follow-ups ( p < 0.05). Conclusion: Varicocele testis is associated with altered testicular haemodynamic, which insults spermatogenesis. Microsurgical varicocelectomy with testicular artery and lymphatic preservation leads to correction of this altered haemodynamic state and improves the testicular microcirculation.

PROSPECTIVE STUDY OF ALTERATION IN TESTICULAR PERFUSION AND VOLUME IN LAPAROSCOPIC TOTALLY EXTRAPERITONEAL HERNIA REPAIR

PURPOSE:- The objective of this study was to assess the effect of Totally extra-peritoneal inguinal hernia repair on testicular perfusion and testicular volume. METHODS: - After obtaining ethical clearance from institutional ethical committee, the present Prospective study was conducted on 48 male patients with unilateral inguinal hernia in a tertiary care hospital. RESULTS: - The study was conducted on 48 patients over a period of 2 years from august 2017 to august 2019 after meeting inclusion and exclusion criteria. Their mean age was 45.70 years (range 21-72 years). In our study comparison of preoperative and postoperative values at third and sixth month in the patients did not show any statistically signicant alteration in the variables studied like testicular volume (p-0.987) and blood ow perfusion parameters Peak systolic velocity (p-0.591); End Diastolic velocity (p-0.526); Resistance index (p-0.415). CONCLUSION: - No alteration in testicular volume and arterial ow over a six-month period was observed among patients who underwent laparoscopic extra-peritoneal surgical correction using polypropylene prosthesis for inguinal hernia

MagicTouch PTA Sirolimus Coated Balloon for Femoropopliteal and Below the Knee Disease: Results From XTOSI Pilot Study Up To 12 Months

Introduction: Sirolimus coated balloon (SCB) is a promising treatment option to prevent restenosis for peripheral arterial occlusive disease (PAOD). This is a pilot first-in-human study of MagicTouch percutaneous transluminal angioplasty (PTA) SCB for treatment of PAOD for both femoropopliteal and below the knee arteries (BTK). Material and Methods: Xtreme Touch-Neo [MagicTouch PTA] Sirolimus Coated Balloon (XTOSI) pilot study is a prospective, single-arm, open-label, single-center trial evaluating MagicTouch PTA SCB for symptomatic PAOD. Primary endpoint was defined as primary patency at 6 months (duplex ultrasound peak systolic velocity ratio ≤2.4). Secondary endpoints included clinically driven target lesion revascularization (CD-TLR), amputation free survival (AFS), all-cause mortality, and limb salvage success. Results: Fifty patients were recruited. The mean age was 67 (n=31 [62%] males). SCB was applied to femoropopliteal in 20 patients (40%) and BTK in 30 patients (60%). Majority of treatments (94%) were performed for limb salvage indications (Rutherford scores 5 or 6). This was a high risk cohort, in which 90% had diabetes, 36% had coronary artery disease, 20% had end stage renal failure, and American Society of Anaesthesiologists (ASA) score was 3 or more in 80%. Mean lesion length treated was 227±81 mm, of which 36% were total occlusions. Technical and device success were both 100%. At 30 days, mortality was 2% and major limb amputation was also 2%. Six-month primary patency was 80% (88.2% for femoropopliteal; 74% for BTK). At 12 months, freedom from CD-TLR was 89.7% (94.1% for femoropopliteal; 86.3% for BTK), AFS was 81.6% (90.0% for femoropopliteal; 75.9% for BTK), all-cause mortality was 14.3% (10.0% for femoropopliteal; 17.2% for BTK), and limb salvage success was 92.9% (94.4% for femoropopliteal; 91.7% for BTK). There was a statistically significant increase between baseline and 6-month toe pressures for both femoropopliteal (57.3±23.3 mm Hg vs 82.5±37.8 mm Hg; p<.001) and BTK lesions (52.8±19.2 mm Hg vs 70.7±37 mm Hg; p<.037). At 12 months, wound healing rate was 33/39 (84.6%). Conclusions: MagicTouch PTA SCB in the XTOSI study showed promising 6-month primary patency and encouraging 12-month freedom from CD-TLR, AFS, and limb salvage rates. No early safety concerns were raised. Randomized trials are needed to investigate the safety and efficacy of SCB for treatment of PAOD.

Transcranial doppler findings in basilar artery dolichoectasia: a case control study

Basilar artery dolichoectasia (BAD) is a disorder characterized by dilatation, elongation and tortuosity of the basilar artery. Transcranial Doppler ultrasound (TCD) is a useful tool that can detect blood flow in intracranial vessels including basilar artery (BA). Few studies have been conducted on blood flow changes in BAD. This study was conducted to evaluate the Doppler parameters in dolichoectatic BA and to assess if there is any difference in TCD findings between stroke and non-stroke BAD patients. A case-control study was conducted on 35 patients diagnosed with BAD (26 male, 9 female) and 35 age- and gender-matched control group (without BAD) at the Middle Euphrates Neuroscience Center, Al-Sader Medical City, Al-Najaf, Iraq. Dolichoectasia was diagnosed on non-enhanced brain CT scan using established imaging criteria according to Dan Deng et al criteria. Doppler flow for control and stroke cases was recorded. The parameters measured on TCD were peak systolic velocity (PSV), end diastolic velocity (EDV) mean blood velocity (MBV), pulsatility index (PI) and resistive index (RI). After logistic regression for adjustment for the significant confounders, there was statistically significant difference in Doppler parameters between both groups including decrease in each of PSV, EDV and MBV while both PI and RI weren’t statistically significant. Among BAD patients, there was statistically significant difference in all TCD parameters between stroke and non-stroke patients (PSV EDV, MBV, PI and RI). BAD was associated with a decrease in flow velocities as measured by TCD. Furthermore, among BAD patients, those with stroke had lower values for all Doppler parameters than non-stroke patients.

Veno-Arterial Index (VAI)—A Promising Tool For Identifying Renal Transplant Rejection

The objective of this study is to evaluate the veno-arterial index (VAI) as a predictor of renal rejection in kidney transplant patients. A diagnostic test study was conducted between January 2014 and May 2018. Renal transplant patients who underwent percutaneous renal biopsy were included. The VAI was obtained by measuring the flow velocity in the renal segmental vein and dividing this value by the peak systolic velocity of the segmental artery in this same location. The records of 77 patients were analyzed. Among these patients, 32 (42%) were positive for transplant rejection and 29 presented with acute rejection. In patients with renal rejection, the median VAI was 0.67 (interquartile range [IQR] = 0.56-0.87), and in kidneys with a negative biopsy for rejection, the median VAI was 0.41 (IQR = 0.27-0.57), with a statistically significant difference ( P = .007) and a value much higher than that obtained for the general population of 0.30 (IQR = 0.18-0.44). Subacute and acute rejected kidneys had an even higher VAI of 0.725 (IQR = 0.57-0.87; P = .0001). Although the resistive index has a good correlation with glomerular filtration, it is not possible by that index to differentiate among the multiple causes that can lead to graft dysfunction. The results of this study show that the VAI might be a useful parameter, which when elevated could predict renal transplant rejection.

Umbilical artery pulsatility index and half-peak systolic velocity in second- and third-trimester fetuses with trisomy 18 and 13

Objectives To analyze umbilical artery (UA) Doppler velocimetry and its possible role in placenta-mediated fetal growth restriction (FGR) in second- and third-trimester fetuses with trisomy 18 and 13. Methods UA pulsatility index (PI) and half-peak systolic velocity deceleration time (hPSV-DT) were measured in fetuses with trisomy 18 and 13. Correlation with gestational age, birthweight, and perinatal outcome was analyzed. Results A total of 80 measurements were taken from 33 fetuses with trisomy 18 and 19 with trisomy 13. Overall, there was a high prevalence of abnormal UA Doppler velocimetry. In fetuses with trisomy 18, 54% (27/50) of the UA PI values and 58% (29/50) of the UA hPSV-DT values were abnormal. In fetuses with trisomy 13, 80% (24/30) of the UA PI values and 87% (26/30) of the UA hPSV-DT values were abnormal. The prevalence of abnormal UA Doppler velocimetry increased with gestational age in both types of aneuploidy. However, this trend was only significant for trisomy 13 (p<0.05). All fetuses with trisomy 18 and 86% of fetuses with trisomy 13 were classified at birth as FGR. There were no perinatal survivors in this series. Conclusions A high prevalence of abnormal UA Doppler velocimetry was found in second- and third-trimester fetuses with trisomy 18 and 13, which further increased with gestational age. These results may well correlate with alterations described previously in the placenta, suggesting placental insufficiency has an important role in the development of FGR in these autosomal aneuploid fetuses.

603 Endothelial dysfunction is associated with hypertensive disorder during pregnancy

Aims Arterial hypertension (AH) is one of the main determinants of clinical disorders during pregnancy affecting 2% to 10% of pregnancies with a substantial public health impact. Both endothelial injury and increased vascular reactivity have been reported to be involved in the pathogenesis of pre-eclampsia syndrome. Abnormal patterns in brachial artery Doppler velocities have been shown to be predictive of pre-eclampsia in first trimester. The aim of this study is to investigate whether flow-mediated dilation (FMD) and Doppler flow derived-parameters can predict the occurrence of AH. Methods and results The study population consisted of pregnant women (mean age 32 years) who had been referred to the IRCCS Fondazione Ca’ Granda Policlinico of Milan. None of them had any medical issues and was taking any medications at the time of pregnancy. FMD was performed on left brachial artery according to expert recommendation. Measurements of brachial artery diameter and flow have been collected at rest, shortly before cuff release and then 5-, 15-, 30-, 60-, and 90-s during hyperaemia phase. Among Doppler measurements, systolic and diastolic velocity (Vs and Vd, respectively) as well as mean velocity (mean V) were considered. In addition, the pulsatility index (PI) and resistance index (RI) were calculated. A 3-months follow-up was planned in order to detect the presence of AH. All data were expressed as the median. U-test (Mann–Whitney analysis) was performed to test difference among hypertensives and non-hypertensives We recruited 48 women (median age 32 yeas) whose 4 (8.5%) developed AH during pregnancy. These latter had statistically significant higher systolic velocity measured at 5 s after the release of distal occlusion (126 cm/s vs. 173 cm/s; P &lt; 0.05). No other velocity Doppler data [diastolic velocity (Vd), mean velocity (mean V), PI, RI, TAMAX, and TAMEAN] showed a statistical significant association with AH development. Conclusions The present study suggests that the vascular assessment through Doppler during FMD procedure may foresee the development of hypertensive disorder in pregnancy. Our result provides the first evidence that the peak systolic velocity of brachial artery may represent a marker of early endothelial activation or damage, that can be directly involved in the pathophysiological mechanisms of the hypertensive disorders in pregnancy.

X-linked sideroblastic anaemia in a female fetus: a case report and a literature review

Background X-linked sideroblastic anaemia (XLSA) is commonly due to mutations in the ALAS2 gene and predominantly affects hemizygous males. Heterozygous female carriers of the ALAS2 gene mutation are often asymptomatic or only mildly anaemic. XLSA is usually characterized by microcytic erythrocytes (reduced mean corpuscular volume (MCV)) and hypochromia, along with increased red cell distribution width. However, in females with XLSA the characteristic laboratory findings can be dimorphic and present with macrocytic (elevated MCV) in addition to microcytic red cells. Case presentation We report a case of fetal anaemia, presenting in the early third trimester of pregnancy, in a female fetus. Ultrasound findings at 29 weeks were of cardiomegaly, prominent umbilical veins, a small rim of ascites, and mean cerebral artery peak systolic velocity (PSV) value above 1.5 Multiples of the Median (MoM). She underwent non-invasive prenatal testing that determined the rhesus genotype of the fetus to be rhesus B negative. No red blood cell antibodies were reported. Other investigations to determine the underlying cause of fetal anaemia included microarray comparative genomic hybridization, serology to exclude congenital infection and a peripheral blood film and fetal bilirubin to detect haemolysis. The maternal grandmother had a history of sideroblastic anaemia diagnosed at the age of 17 years. The mother had mild macrocytic anaemia with haemoglobin of 10.4 g/dl and MCV of 104 fl. The fetal anaemia was successfully treated with two in utero transfusions (IUTs), and delivery occurred via caesarean section at 37 weeks of gestation. The red cell gene sequencing in both the mother and fetus were heterozygous for an ALAS2 mutation causing in utero manifestations of XLSA. The haemoglobin on discharge to the local hospital at five days of age was 19.1 g/dl. Subsequently, the infant became anaemic, requiring regular 3–4 monthly blood transfusions and demonstrating overall normal development. Her anaemia was unresponsive to pyridoxine. Conclusions This is one of four cases reporting multiple female members presenting with discordant clinical features of XLSA from being entirely asymptomatic to hydropic in utero. Our report is novel in that there are no previous cases in the literature of anaemia in a female fetus heterozygous for ALAS2 mutation.