Associations of circulating biomarkers with the presence and severity of coronary, carotid and femoral arterial atherosclerosis

Aim. To identify and characterize the associations of the presence and severity of atherosclerosis of various localization with the blood level of biochemical parameters, as well as to assess the potential of their use as markers of metabolic disorders with increased atherogenic potential.Material and methods. The study included 216 patients (men, 53%) aged 24-87 years (mean age, 61,5±10,73 years). All patients underwent coronary angiography, carotid (CA) and femoral arterial (FA) duplex ultrasound to assess the presence and severity of atherosclerosis. In blood serum/plasma, biochemical parameters were analyzed using standard methods.Results. Based on the analysis of circulating biomarker profile, diagnostic complexes have been established that allow assessing atherosclerosis of different localization. According to the data obtained, the determinants of coronary and CA atherosclerosis are endothelial dysfunction (concentration of nitric oxide metabolites <36,0 μmol/L) and an increased level of creatinine (≥73,0 μmol/L). The specific markers associated with severe atherosclerosis of coronary and FAs (but not CA) were low high-density lipoprotein cholesterol (≤1,0/1,2 μmol/L for male/ female, respectively) and an increased C-reactive protein level (≥1,0 mg/l). Severe peripheral atherosclerosis (CA and FA involvement) was associated with hyperglycemia (glucose ≥6,1 μmol/L), while severe FA atherosclerosis — with hyperinsulinemia (insulin ≥14,0 μU/ml).Conclusion. The analysis of associations of circulating biochemical parameters with atherosclerosis localization and severity revealed a number of metabolic markers associated with the increased atherogenic potential. It is possible to distinguish both universal parameters that are associated with atherosclerosis, regardless of its localization and/or severity, and specific biomarkers that characterize either the localization or the severity of atherosclerosis, or both.

A Popliteal Vein Aneurysm Accompanied by Lower Persistent Sciatic Vein

Popliteal venous aneurysms (PVAs) are rare. Surgical treatment is recommended because of the risk of deep vein thrombosis and fatal pulmonary embolism. A persistent sciatic vein (PSV) is also a rare anomaly. We report a case of a PVA accompanied by a lower PSV. A 70-year-old man was admitted due to left leg heaviness. He had undergone ablation of both great saphenous veins 6 years prior to the admission. Duplex ultrasound showed a PVA on his left leg, which was 3.2 × 2.4 cm in size. The patient was treated with tangential aneurysmectomy with lateral venorrhaphy. His symptom gradually resolved. He received warfarin at a therapeutic range for 3 months. Duplex ultrasound at 6 months later showed no evidence of any recurrent aneurysm or venous reflux. His follow-up has revealed no complications for 18 months. Surgical treatment and perioperative therapeutic anticoagulation are recommended for treating PVAs. Tangential aneurysmectomy with venorrhaphy is the most common and the simplest surgical method.

The Emerging Clinical Utility of Neurosonology During COVID-19 Pandemic

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 infection. Over the last 2 years the virus has spread worldwide with enormous implications on the healthcare systems. COVID-19 patients suffer from mild upper-airway manifestations to pneumonia and severe acute respiratory distress syndrome and their hospitalizations are often prolonged. Neurological manifestations of the disease are common. Neurosonology (transcranial Doppler & cervical duplex ultrasound) is an easily repeatable diagnostic imaging modality that can be simply applied at the bedside of COVID-19 patients with cerebrovascular diseases or in critically ill patients in the intensive care unit. Neurosonology may provide hemodynamic assessment of cerebral circulation, quantitative evaluation of increased intracranial pressure and detection of micro-embolic signals in real-time. Consequently, it may assist substantially in the diagnosis, risk stratification and therapeutic approach of COVID-19 patients with or without cerebrovascular complications. In the present narrative review, we discuss the emerging clinical utility of neurosonology during COVID-19 pandemic and highlight the upgraded role of neurosonology resulting from the combination of the established applications coupled with the reduced risk of virus spreading during ultrasound evaluation compared to other imaging modalities including computed tomography and magnetic resonance imaging.

Endovascular salvage of failing arterio-venous fistulas utilising sirolimus eluting balloons: Six months results from the ISABELLA trial

Background: Aim of this pilot clinical study was to evaluate the safety and efficacy of the Selution Sustained Limus Release (SLR)™ sirolimus-eluting balloon (SEB) for improving failing arterio-venous fistulas (AVF) patency in Asian haemodialysis patients. Methods: Prospective single-centre, multi-investigator, non-consecutive, non-blinded single arm trial. Forty end-stage renal failure Asian patients with a dysfunctional AVF underwent SEB angioplasty between May and November 2020. All stenotic lesions were prepared with high pressure non-compliant balloon angioplasty prior to SEB angioplasty. Endpoints of interest included target lesion primary patency and circuit access patency and safety through 30 days. All patients received dual antiplatelet therapy for 1 month and were followed up with Duplex ultrasound at 6 months. Results: There was one subject dropout so final n = 39 patients (mean age 65.0 ± 11.9; males = 26 (66.7%)) and n = 43 target lesions treated. Main indication for intervention was dropping access flow (24/39; 61.5%) and most common target lesion was in the juxta-anastomosis (24/43; 54.5%). There was 100% technical and procedural success. There were no adverse events related to the SEB. Target lesion primary patency rates at 3 and 6 months were 39/41 (95.1%) and 28/39 (71.8%) respectively. Access circuit patency rates at 3 and 6 months were 35/37 (94.6%) and 22/35 (62.9%) respectively. There were 3 (7.7%) deaths all attributable to patients’ underlying co-morbidities. Conclusions: Fistuloplasty using the novel Selution SLR™ SEB for dysfunctional AVF circuits seems a safe and effective modality in Asian haemodialysis patients at 6 months but larger randomised controlled studies are required now to determine its true efficacy against plain balloon angioplasty.

Flow volume measured by duplex ultrasound in native arteriovenous fistula for hemodialysis: a case report

Background : Native arteriovenous fistula (AVF) is the vascular access of choice for hemodialysis patients. AVF lasts longer than artificial grafts or central venous catheters. In addition, AVF has fewer complications than other vascular accesses. The use of Doppler ultrasound is used to facilitate fistula construction (vascular mapping) including AVF maturation to see if AVF can be used. Doppler ultrasound monitoring for maturation of AV fistulas should be monitored sonographically until the fistula is ready for use, especially when maturation is slow and in patients whose veins cannot easily be assessed by physical examination alone (eg because of obesity). The AVF DUS flow volume measurement may be the only imaging tool that can be used to monitor a fistula even during its maturation. Even so, DUS should always be done before AVF is used for the first time. This examination provides baseline data on vascular access, which can be useful in subsequent tests performed to evaluate functional problems. Case report : A man, 52 years old who has done AV Fitula two weeks ago. Currently patients are using a double lumen catheter (CDL) for routine hemodialysis. One day the patient had his CDL removed. Even though the patient feels thrill in the AV fistula, the nephrorologist still doubts whether the AV fistula is ripe and can be used. For this reason, a Duplex Ultrasound is performed to assess the diameter, velocity flow, PSV and TAMV .By positioning the sample volume in the presumed stenosis site, the Doppler velocity test detects a systolic peak velocity. Conclusion: Color flow Doppler imaging should be used as a tool to screen for areas of high velocity and to aid in the optimal placement of the pulsed Doppler sample volume. The pulsed Doppler sample volume should be set at the smallest size possible to detect discrete changes in blood flow meanwhile doppler ultrasound should be use in monitoring for maturation of AV fistulas

Ovarian Vein Embolization With N-butyl-2 Cyanoacrylate Glubran-2® for the Treatment of Pelvic Venous Disorder

Background: There are few reports in the literature on the use of Glubran-2 for the embolization of ovarian veins in patients with pelvic venous disorder (PeVD). In addition, a consensus on the efficacy and safety of Glubran-2 has not been reached.Purpose: To investigate the safety and efficacy of ovarian vein embolization (OVE) with N-butyl-2 cyanoacrylate (NBCA) Glubran-2 for the treatment of PeVD.Material and Methods: Between January 2013 and January 2020, 21 women (mean age, 43.9 ± 13.3 years) with PeVD who underwent OVE with Glubran-2 were evaluated. Of those patients, ovarian vein or pelvic venous plexus insufficiency was verified by duplex ultrasound and/or multislice computer tomography (MSCT). The symptoms and signs of PeVD included chronic pelvic pain (CPP) (21/21; 100%), dyspareunia (12/21; 57.1%), dysmenorrhea (10/21; 47.6%), and vulvar varices (3/21; 14.3%). The medical data were retrospectively reviewed.Results: Glubran-2 was employed as the sole embolic material in 18 cases (85.7%) and used to perform rescue embolization in 3 cases (14.3%) due to CPP recurrence 1 month after initial embolization using microcoils. Technically successful embolization was achieved using Glubran-2 in all patients. No Glubran-2 related complications were noted. Neither persistent nor recurrent CPP was observed during follow-up, for which the mean was 62 ± 38 months (range, 12–102 months). Clinical efficacy was evaluated, and all patients exhibited complete or slight improvement of CPP after embolization. The visual analog scale (VAS) score significantly decreased from pre-intervention to post-intervention (p &lt; 0.001). Six patients (28.6%) gave birth to healthy babies during follow-up after embolization with Glubran-2.Conclusions: Ovarian vein embolization with Glubran-2 is a feasible and safe treatment for CPP secondary to PeVD. This treatment may represent a potential and attractive alternative when patients desire symptom relief and want to continue reproducing. Larger studies are warranted to confirm the findings of this study.

Prevalence and Risk Factors of Arterio-Venous Fistula Obstruction on Patient with Chronic Kidney Disease

Prevalence and Risk Factors of Arterio-Venous Fistula Obstruction on Patient with Chronic Kidney Disease Ismail MT1, Hariawan H1, Wardhani Y2, Puspitasari M2, Artayasa IPA1, Ramadhan G1, Tarigan T1, Triatmaja R1 1Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, 55284, Indonesia 2Department of Internal Medicine Faculty of Medicine Universitas Gadjah Mada-RSUP Dr. Sardjito Yogyakarta Indonesia ABSTRACT Aim: AV fistula obstruction has become one of the main vascular access complications in patients undergoing haemodialysis. This complications have significant impacts on the morbidity and mortality of dialysis patients while also leading to higher medical costs. Clinical monitoring has been routinely used for early detection of AV fistula stenosis and obstruction, however screening with Doppler ultrasound is still not a routine recommendation. This study aims to know prevalence and risk factors of AV Fistula obstruction detected by Duplex ultrasound examination. Methods: This study was a hospital-based descriptive analytic study with cross sectional design conducted at the haemodialysis center of National General Hospital Dr. Sardjito, Yogyakarta, Indonesia. Patient demographic and clinical risk factor were recorded using direct interview. AV fistula obstruction were assessed using Duplex ultrasound by professional sonographer. Results: Seventy four (74) patients are using AV fistula as entry access for hemodialysis in RSUP dr. Sardjito. It is consist of 39 male (53%) and 35 Female (47%). The mean age of patients is 50 years old. Surveillance using Doppler ultrasound found 20 patients (27%) have stenotic AV Fistula. Smoking habits (OR 5.37, 95% CI, 1.760 - 16.431, p=0.002) and diabetes mellitus (OR 5.00, 95% CI, 1.631 – 15.503, p=0.004) increase risk for having stenotic AV fistula. Only 4 patient (20 %) of all 20 patient with stenotic AV fistula were symptomatic, and needed for further vascular intervention Conclusion: Prevalence of AV fistula obstruction detected by Doppler ultrasound was 27% of all AV fistula patient with only 5% had symptomatic AV fistula failure. Smoking habits and diabetes mellitus are important risk factor for AV fistula obstruction. Asymptomatic AV fistula obstruction often goes undetected by clinical monitoring that can increase of risk of symptomatic AV fistula obstruction in the future. The further study is needed to determine level recommendation of routine AV fistula surveillance with Doppler Ultrasound. Key words: AV Fistula obstruction, CKD, Doppler ultrasound surveillance, Risk factors, Prevalence

Stimulation TcPO2 Testing Improves Diagnosis of Peripheral Arterial Disease in Patients With Diabetic Foot

BackgroundAll diagnostic procedures of peripheral arterial disease (PAD) in diabetic foot (DF) are complicated due to diabetes mellitus and its late complications.The aim of our study is to enhance diagnosis of PAD using a novel transcutaneous oximetry (TcPO2) stimulation test.MethodsThe study comprised patients with mild-to-moderate PAD(WIfI–I 1 or 2) and baseline TcPO2 values of 30-50 mmHg.TcPO2 was measured across 107 different angiosomes. Stimulation examination involved a modification of the Ratschow test. All patients underwent PAD assessment (systolic blood pressures (SBP), toe pressures (TP), the ankle-brachial indexes (ABI) and toe-brachial indexes (TBI), duplex ultrasound of circulation). Angiosomes were divided into two groups based on ultrasound findings: group M(n=60) with monophasic flow; group T(n=47) with triphasic flow. Large vessel parameters and TcPO2 at rest and after exercise (minimal TcPO2, changes in TcPO2 from baseline (Δ,%), TcPO2 recovery time) measured during the stimulation test were compared between study groups.ResultsDuring the TcPO2 stimulation exercise test, group M exhibited significantly lower minimal TcPO2 (26.2 ± 11.1 vs. 31.4 ± 9.4 mmHg; p&lt;0.01), greater Δ and percentage decreases from resting TcPO2 (p=0.014 and p=0.007, respectively) and longer TcPO2 recovery times (446 ± 134 vs. 370 ± 81ms;p=0.0005) compared to group T. SBPs, TPs and indexes were significantly lower in group M compared to group T. Sensitivity and specificity of TcPO2 stimulation parameters during PAD detection increased significantly to the level of SBP, ABI, TP and TBI.ConclusionCompared to resting TcPO2, TcPO2 measured during stimulation improves detection of latent forms of PAD and restenosis/obliterations of previously treated arteries in diabetic foot patients.Clinical Trial RegistrationClinicalTrials.gov [https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0009V7W&amp;selectaction=Edit&amp;uid=U0005381&amp;ts=2&amp;cx=3j24u2], identifier NCT04404699

A Possible Role for Arterial Duplex and Hand Acceleration Time in Diagnosing and Managing Shock

Shock represents a state when arterial perfusion is inadequate to supply the needs of cellular respiration, leading to anerobic metabolism, acidosis, and cell death. Although typically described in terms of blood pressure and heart rate, these measures can both lead to delayed recognition of shock and under appreciation of the severity of end-organ malperfusion. Recently, there has been increased interest in monitoring peripheral perfusion both to detect early shock and monitor the response to treatment. However, current methods are variable and, in some cases, require specialized equipment. We present a case in which duplex ultrasound assessment of peripheral palmar acceleration time identified a post-hemorrhagic shock state before it was clinically apparent. Bedside arterial duplex and hand acceleration time may provide a simple tool to assess the degree of shock and response to intervention.