Noninvasive investigations in vascular disease. St Mary's Fellows. ISVI (Italian Society for Vascular Investigations).
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Arterial Occlusive Diseases↗
Biomedical subjects
G Geroulakos
Publications and source records attributed to G Geroulakos.
Treatment of severe intermittent claudication with PGE1--a short-term vs a long-term infusion plan--a 20 week, European randomized trial--analysis of efficacy and costs.
The efficacy, safety, and cost of prostaglandin E1 (PGE1) in the treatment of severe intermittent claudication was studied by comparing a long-term treatment protocol (LTP) with a short-term treatment protocol (STP) in a randomized 20-week study. The study included 109 patients (96 completed the study) with an average total walking distance of 65.5 +/- 8 m (range 20-109). Phase 1 was a 2-week run-in phase (no treatment) for both protocols. In LTP, phase 2 was the main treatment phase. In the LTP, treatment was performed with 2-hour infusions (60 microg PGE1, 5 days each week for 4 weeks). In phase 3 (4-week interval period) PGE1 was administered twice a week (same dosage). In phase 4 (monitoring lasting 3 months, from week 9 to 20) no drugs were used. In STP, phase 2 treatment was performed in 2 days by a 2-hour infusion (1st day: morning 20 microg, afternoon 40 microg; 2nd day morning and afternoon 60 microg). The reduced dosage was used only at the first cycle (week 0) to evaluate reduced tolerability or side effects. Full dosage (60 microg b.i.d.) was used for all other cycles. The same cycle was repeated at the beginning of weeks 4, 8, and 12. The observation period was between weeks 12 and 20. A treadmill test was performed at inclusion, at the beginning of each phase, and at the end of the 20th week. A similar progressive physical training plan (based on walking) and a reduction in risk factors levels plan was used in both groups. Intention-to-treat analysis indicated an increase in walking distance, which improved at 4 weeks (101.5% in STP vs 78.3% in LTP), at 8 weeks (260.9% STP vs 107.3% LTP), and at 20 weeks (351% STP vs 242% LTP). Comparable increases in pain-free walking distance were observed in the two groups. No serious drug-related side effects were observed. Local, mild adverse reactions were seen in 7% of the treated subjects in the LTP and 5% in the STP. Average cost of LTP was approximately 6,588 ECU; for STP the average cost was approximately 1,881 ECU. The cost to achieve an improvement in walking distance of 1 m was 35.6 ECU with the LTP and 9.45 ECU with the STP (26% of the LTP cost; p<0.02). For an average 100% increase in walking distance the LTP cost was 1,937 ECU vs 550 ECU with STP (p<0.02). The cost of PGE1 (including infusion and operative costs) was 25% of the total cost for LTP (24.9% for STP). In summary, between-group-analysis favors STP, in terms of walking distance and costs. Results indicate good efficacy and tolerability of PGE1 treatment. With STP less time is spent in infusion and more can be spent in the exercise program. STP reduces costs, speeds up rehabilitation, and may be used in a larger number of nonspecialized units available to follow the protocol.
Alprostadil↗
Effect of renal-artery stenting on progression of renovascular renal failure.
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Angioplasty, Balloon↗
Use of the splenic and hepatic artery for renal revascularization in patients with atherosclerotic renal artery disease.
Hepatorenal and splenorenal bypasses are gaining an increased popularity as an alternative to renal artery endarterectomy and aortorenal bypass in selected patients. However, there are few reports of the long-term results of this procedure. The purpose of this study was to assess the performance of the hepatic and splenic arterial sources in patients with atherosclerotic renal artery disease. We reviewed our 7-year experience between 1988-1995. A total of 146 operative renal artery reconstructions were performed, including 45 hepatorenal and/or splenorenal bypass in 38 patients, (19 male, 19 female, mean age 62 +/- 12 years) for treatment of renovascular hypertension, renal preservation or both. The mean preoperative creatinine was 2.95 mg/dl (2.11-3.47, 95% confidence limits). The average number of antihypertensive medications was 2.63. There was one postoperative death from myocardial infarction and two cases of early graft thrombosis, one of which was treated by thrombectomy reestablishing patency. In two patients with persistent hypertension selective angiography demonstrated high-grade anastomotic stenoses which were successfully dilated by balloon angioplasty. The postoperative mean creatinine decreased to 2.54 mg/dl (1.82-3.27, 95% confidence limits), (p = 0.17) and the average number of antihypertensive medications decreased to 1.9 (p = 0.001). During the median follow-up of 33 months, 10 patients died, mainly from cardiac causes. Our experience indicates that the splenic and hepatic arteries provide useful alternatives to renal revascularization in selected circumstances with an acceptable rate of perioperative mortality and morbidity. The expected long-term survival in this group of patients is low.
Anastomosis, Surgical↗
Factors influencing the long-term results of abdominal aortic aneurysm repair.
The incidence of late graft complications such as para-anastomotic aneurysms, aortoenteric fistulas and graft infections following abdominal aortic aneurysm (AAA) repair is a major determinant of its overall benefit, yet most published reports of AAA repair have concentrated almost exclusively on the early postoperative mortality and morbidity. Accurate knowledge regarding the incidence of late complications is essential to making any decision regarding the operative vs nonoperative management of AAAs. A similar analysis must be applied to endovascular repair of AAAs before this technique is accepted as an alternative method of treating AAAs. In this article we review the current knowledge and understanding on the late results following aortic aneurysm repair.
Anastomosis, Surgical↗
Carotid surgery and ocular ischaemia.
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Endarterectomy, Carotid↗
Venous elasticity after treatment with Daflon 500 mg.
It has been demonstrated that patients predisposed to the development of varicose veins have an abnormal venous tone, and may have symptoms in the absence of obvious varicosities. It has been suggested that venotonic drugs relieve the symptoms of chronic venous insufficiency by decreasing capillary leakage and improving venous tone. The aim of this study was to determine the effect of Daflon 500 mg in patients with abnormal venous elasticity without varicose veins. Twenty-five healthy female volunteers aged 18-35 were included in the study. They presented with symptomatic varicose veins in one leg and an abnormal elastic modulus without varicosities in the opposite leg. Treatment group: 12 patients received 2 tablets of Daflon 500 mg (1000 mg/day); control group: 13 patients received no treatment. The elastic modulus K was determined using the air plethysmograph. Simultaneous measurements of calf volume changes were made in response to different venous pressures produced by a thigh pneumatic cuff. In the control group K (mean +/- sd) was 10.8 x 10(3) +/- 4.1 x 10(3) N/m2 at the beginning and 10.2 x 10(3) +/- 3.1 x 10(3) N/m2 at the end of the study (P > 0.1). In the treatment group the initial K was 10.2 x 10(3) +/- 3.9 x 10(3) N/m2 and 14.2 x 10(3) +/- 5.1 x 10(3) N/m2 at the end (P < 0.02). The results of the Wilcoxon rank sum test indicated that 4 weeks' therapy with Daflon 500 mg is effective in improving venous tone in patients with symptoms but without varicose veins.
Adolescent↗
The ultrasonic evaluation of the carotid intima-media thickness and its relation to risk factors of atherosclerosis in normal and diabetic population.
High-resolution ultrasound provides an excellent tool for the non-invasive assessment of the severity of atherosclerosis. It allows the measurement of the common carotid artery (CCA) intima media thickness (IMT) which has been found to be a feasible and reliable method for the evaluation of the progression and regression of the disease. The aim of this study was to evaluate the influence of risk factors of atherosclerosis on the mean CCA IMT in both normal and non-insulin dependent diabetic (NIDDM) individuals and to determine the effect of diabetes as a major atherosclerotic risk factor on the CCA IMT. Four hundred and eighty-four subjects were studied, 244 normal individuals and 240 non insulin dependent diabetic patients. The right and left CCA IMT were measured using high resolution ultrasonography. Both in the normal and diabetic individuals, the mean CCA IMT was found to increase linearly with age (p < 0.01), was directly related to total serum cholesterol and triglyceride and inversely related to HDL-cholesterol (p < 0.01). Multiple linear regression analysis showed the most important risk factor influencing the CCA IMT and hence early athrosclerosis to be the presence of diabetes, followed by serum HDL-cholesterol (inverse relation), total cholesterol, age and serum triglyceride. This study has shown that high resolution ultrasonography can be used to evaluate the effect to risk factors on early atherosclerosis and could be used to monitor future clinical trails aiming to modify the progression of atherosclerosis in the population.
Adult↗
Cholesterol embolisation. A lethal complication of instrumentation of an aneurysmal aorta: a case report.
A case of cholesterol embolisation (CE) following instrumentation of an aneurysmal aorta is presented. The patient developed myalgias, livedo reticularis in the buttocks, suprapubic area and legs, that progressed to patchy gangrene and renal failure. Maximum conservative management including heparin, iloprost and haemodialysis was ineffective, in keeping with previous reports that there is no known therapy for CE. The aetiology, presentation, treatment and prognosis of this condition is discussed. With the ever increasing use of endovascular treatment of abdominal aortic aneurysms, this complication may be more frequently encountered.
Aged↗
Circadian pattern of post-surgical fatal pulmonary embolism.
BACKGROUND: The circadian distribution of fatal pulmonary thromboembolism in general surgical patients is unknown. PATIENTS AND METHODS: One hundred consecutive cases of pulmonary embolism, with reliable clinical notes and data, were studied (67 men and 33 women; mean age 71 years). Only post-surgical cases were considered in this analysis. Patients had undergone elective (78%) or emergency abdominal surgery (22%). Correct prophylaxis (according to the Windsor Consensus Statement) had been used in 12%. Cases were grouped according to the time of onset of signs and symptoms related to pulmonary embolism at one hour intervals. RESULTS: The maximum incidence of fatal pulmonary embolism was between 7.00 a. m. and 1.00 p. m. with the highest peaks at 9.00 and 11.00 a. m. 9% of deaths) (P < 0.02). When results from this study were compared to a previous study no significant difference was observed between the distribution profile of cases from general medical wards and surgical wards. CONCLUSION: It appears that in surgical patients there is a circadian pattern in pulmonary embolism as already documented in medical patients.
Aged↗
Relative fasting hypoinsulinaemia and ultrasonically measured early arterial disease in type 2 diabetes. The SENDCAP Study Group, St. Mary's, Ealing, Northwick Park Diabetes Cardiovascular Disease Prevention Study.
Macrovasular disease is the most important cause of morbidity and mortality in Type 2 (non-insulin-dependent) diabetes. Dyslipidaemia and hyperinsulinaemia have been proposed as aetiological factors. This paper describes the interrelationships between fasting serum insulin, serum lipids, and the extent of ultrasonically measured early arterial disease in Type 2 diabetic subjects screened for entry into a prospective study set up to ascertain whether improving serum lipids can alter the progress of arterial disease in Type 2 diabetes. Measurements were made of the initima media thickness (IMT) in the carotid artery, and an arterial ultrasound score (AUS) based on appearances of both carotid and femoral arteries was calculated for 192 established Type 2 diabetic subjects, males and females, mean age 51 (range 35-66) years, median duration of diabetes 3.5 years, with no known cardiovascular disease. Multiple regression analysis showed that carotid IMT increased with age and was inversely related to serum insulin (variance accounted for, R2, = 8.8%, p = 0.0002). AUS increased with age and was related inversely to serum insulin, or to C-peptide when this was substituted in the model. In addition to age and serum insulin, AUS was positively associated with non-HDL cholesterol and negatively with HDL 3 cholesterol (R2 = 26%, p = 0.0001). Early thickening and damage to the arterial wall in Type 2 diabetes may be related to relative fasting hypoinsulinaemia.
Adult↗
Ultrasonographic carotid plaque morphology in predicting stroke risk.
A number of new studies have provided evidence which suggests that carotid plaque surface characteristics and internal structure, as seen on ultrasonography, contribute to the development of cerebrovascular endpoints. This review is a critical presentation of the evidence that has emerged so far supporting the hypothesis that the ultrasonographic morphology of the carotid plaque may be an independent variable in predicting the risk of stroke. It is concluded that ultrasonographic plaque morphology should be used together with other local risk factors in prospective natural history studies which aim to identify a subgroup of patients at high risk of stroke.
Carotid Artery Diseases↗
Effect of carotid endarterectomy on the ocular circulation and on ocular symptoms unrelated to emboli.
OBJECTIVE: To evaluate haemodynamic changes in the ophthalmic artery and the retina following carotid endarterectomy and their effect on the pathophysiology of the eye. DESIGN: Prospective study. METHOD: Twenty-two consecutive patients with severe carotid stenosis underwent 23 carotid endarterectomies and one subclavian-carotid bypass. The following measurements were made preoperatively and 3 months after operation; Ophthalmic artery (OA) and retinal arteriole (RA) peak systolic velocity (PSV) and peak diastolic velocity (PDV), macular photostress recovery time, visual acuity, intraocular pressures, colour vision and visual fields testing. RESULT: The RA PSV increased by 50% (p = 0.005) and PDV increased by 22% (p = 0.03). The OA PSV increased by 51% (p = 0.001). Macular photostress testing decreased from 58 s to 42 s (p = 0.001). Visual acuity improved in four and was unchanged in 13 eyes ipsilateral to the endarterectomy which had abnormal preoperative measurements. One patient experienced a dramatic increase in the ipsilateral intraocular pressure associated with visual deterioration. In two patients there was resolution of periorbital pain. CONCLUSION: Our results demonstrate an increase in the PSV of the RA and OA following carotid surgery. There are pathophysiological changes in the eye, which accompany tight stenotic extracranial carotid artery disease and these may be influenced by carotid endarterectomy.
Aged↗
The identification of the high risk carotid plaque.
OBJECTIVE: To determine the influence of carotid plaque morphology and severity of stenosis on symptoms of cerebrovascular disease and cerebral infarction. PATIENTS AND METHODS: One hundred and ninety patients with 329 carotid plaques producing 50-99% stenosis were studied. Carotid plaque echogenicity on ultrasonography was evaluated using computerised measurement of the median of the overall grey scale content (GSM). Heterogeneity was evaluated as the difference between the GSMs of the most echogenic and the most echolucent areas within each plaque and expressed as the heterogeneity index (HI). All patients had a CT brain scan and the presence of ipsilateral cerebral infarction noted. RESULTS: Cerebral infarction was more common in symptomatic than asymptomatic plaques (42% vs. 29%, p<0.02) and in echolucent than echogenic plaques (mean GSM of 37.8 vs. 29.7, p<0.01). Plaques with GSM below or equal to 32 were associated with a higher incidence of cerebral infarction as compared to those above this level, this was significant in both symptomatic and asymptomatic plaques. Symptomatic carotid plaque were less heterogenous than asymptomatic plaques. Plaques associated with cerebral infarction were less heterogenous than those not associated with infarction. CONCLUSION: This study has shown that the identification of the high risk carotid plaques, i.e. those associated with a high incidence of cerebral infarction is possible both in symptomatic and asymptomatic patients. The potential of such analysis in the identification of patients with asymptomatic carotid stenosis with high and low risk of stroke should be explored in a natural history study.
Carotid Stenosis↗
Ancrod: clinical indications and methods of use.
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Ancrod↗
The relative effect of carotid plaque heterogeneity and echogenicity on ipsilateral cerebral infarction and symptoms of cerebrovascular disease.
OBJECTIVE: To determine the relative effect of carotid plaque heterogeneity and echogenicity as measured by computer on the incidence of ipsilateral cerebral infarction and symptoms of cerebrovascular disease. MATERIALS AND METHODS: 138 patients with 209 carotid plaques producing > 50% stenosis were studied. 110 plaques were from symptomatic sides. All patients had computer tomography (CT) brain scans. Images of the carotid plaques obtained by duplex scanner were transferred to a computer. Using an image analysis program plaque echogenicity, measured as the grey scale median (GSM) and heterogeneity, evaluated as the heterogeneity index (HI) was calculated. RESULTS: 42% of plaques were associated with cerebral infarction. Symptomatic plaques and those associated with cerebral infarction were more echolucent and less heterogeneous than asymptomatic plaques and those not associated with cerebral infarction. Plaques with GSMs below or equal to 32 were associated with a significantly higher incidence of cerebral infarction. Plaques with GSMs below or equal to 32 were associated with a significantly higher incidence of cerebral infarction and symptoms of cerebrovascular disease than those with GSMs above this level (p < 0.01). Plaques with HIs below or equal to 20 were associated with a significantly higher incidence of symptoms of cerebrovascular disease as compared to those with HIs above this level (p < 0.01). CONCLUSIONS: Computer analysis of carotid plaque morphology is an objective tool that can identify high risk plaques. The potential of such analysis in the identification of asymptomatic patients with advanced carotid stenosis at a high risk of stroke should be explored in a natural history study.
Arteriosclerosis↗
Venous hemodynamic abnormalities in patients with leg ulceration.
PURPOSE: Venous ulceration in the leg has been predominantly associated with deep venous insufficiency, although a few reports have implicated the superficial veins. The aim of this study was to identify the distribution of valvular incompetence in patients with active leg ulceration. PATIENTS AND METHODS: Color flow duplex imaging (CFDI) ultrasonography was used to evaluate the entire venous system--superficial, perforator and deep--from groin to ankle in 112 limbs of 94 patients with venous leg ulcers. RESULTS: Seventy two limbs (64%) had multisystem incompetence and 36 (32%) had one system involved only, whereas in 4 limbs (4%) there was no venous incompetence. Deep venous reflux exclusively was present in 7 limbs (6%) and the perforator system alone was involved only in 3 limbs (3%). However, isolated superficial incompetence was seen in 26 extremities (23%) and combination of superficial with perforator system alone in 23 (21%). In addition, reflux overall in the superficial system (alone and in combination with perforator and deep systems) was seen in 94 limbs (84%). The most common pattern (28%) of abnormality was reflux in all systems, superficial, perforator, and deep. CONCLUSIONS: The results of this study show that variable combined patterns account for over two thirds of patients with ulceration. No comprehensive surgical policy for alleviating ulceration can be justified; we suggest that a complete evaluation of all venous systems from groin to ankle with CFDI ultrasonography in patients with venous ulceration is practical on a routine basis and will be particularly valuable before surgery in order to target intervention at specific incompetent sites.
Adolescent↗