Cocaine-related vasculitis causing upper-limb peripheral vascular disease.
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Cocaine-Related Disorders↗
Biomedical subjects
P C Spittell
Publications and source records attributed to P C Spittell.
Intermittent claudication: an objective office-based assessment.
OBJECTIVES: We sought to compare standard lower extremity vascular laboratory treadmill exercise with the office-based active pedal plantarflexion technique. BACKGROUND: Intermittent claudication is relatively common in elderly patients and is an important predictor of cardiovascular morbidity and mortality. Noninvasive testing using resting and posttreadmill exercise ankle:brachial systolic blood pressure indices is often required to confirm the diagnosis and objectively assess the severity of lower extremity arterial occlusive disease. This is traditionally performed in a formal vascular laboratory setting. METHODS: Fifty consecutive patients (100 lower extremities) with known or suspected intermittent claudication referred for lower extremity treadmill exercise testing were also tested with active pedal plantarflexion using a prospective, randomized crossover design. Supine ankle:brachial systolic blood pressure indices were measured immediately before and after each form of exercise. RESULTS: There was an excellent correlation (r = 0.95, 95% confidence interval 0.93 to 0.97) between mean postexercise ankle:brachial systolic blood pressure indices for treadmill exercise and active pedal plantarflexion. There was no significant difference in outcome based on the order of testing or the severity of arterial occlusive disease. Symptoms of angina or dyspnea occurred in 11 patients (22%) with treadmill exercise versus zero patients with active pedal plantarflexion. CONCLUSIONS: Active pedal plantarflexion is an office-based test that compares favorably with treadmill exercise for the noninvasive, safe, objective and economical assessment of lower extremity arterial occlusive disease.
Aged↗
Association of atrial fibrillation and aortic atherosclerosis: a population-based study.
OBJECTIVE: To examine the association between atrial fibrillation (AF) and aortic atherosclerosis in the general population. SUBJECTS AND METHODS: Transesophageal echocardiography was performed in 581 subjects, a random sample of the adult Olmsted County, Minnesota, population (45 years of age or older) participating in the Stroke Prevention: Assessment of Risk in a Community (SPARC) study. The frequency of aortic atherosclerosis was determined in 42 subjects with AF and compared with that in 539 subjects without AF (non-AF group). RESULTS: Subjects with AF were significantly older than non-AF subjects (mean +/- SD age, 82+/-10 vs 66+/-13 years, respectively; P<.001) and more commonly had hypertension (28 [66.7%] vs 288 [53.4%], respectively; P=.10). The 2 groups were similar in sex and frequency of diabetes mellitus, hyperlipidemia, or smoking history (P>.10). The odds of aortic atherosclerosis (of any degree) were 2.87 times greater (95% confidence interval [CI], 1.41-5.83; P=.004) and the odds of complex atherosclerosis (protruding atheroma >4 mm thick, mobile debris, or plaque ulceration) were 2.71 times greater (CI, 1.13-6.53; P=.03) in the AF group than in the non-AF group. Age was a significant predictor of aortic atherosclerosis (P<.001). After adjusting for age, the odds of atherosclerosis and complex atherosclerosis were not significantly different between the 2 groups (P=.13 and P=.75, respectively). CONCLUSIONS: In the general population, AF is associated with aortic atherosclerosis, including complex atherosclerosis. This association is related to age since both AF and aortic atherosclerosis are more frequent in the elderly population.
Adult↗
Severe digital arterial occlusive disease and acute parvovirus B19 infection.
We report a case of arterial occlusive disease and digital ischaemia associated with acute parvovirus B19 infection. Treatment with intravenous epoprostanol improved her symptoms.
Adult↗
Mobile thrombi in the abdominal aorta in cases of lower extremity embolic arterial occlusion: value of extended transthoracic echocardiography.
BACKGROUND: Lower extremity embolic arterial occlusion is often associated with proximal atherosclerotic and/or aneurysmal disease. Fixed atherosclerotic disease of the abdominal aorta has been demonstrated by ultrasonography, tomographic studies, and aortography, but mobile debris has not previously been described. We report detection of mobile thrombi in the abdominal aorta during transthoracic echocardiography screening in 6 patients with lower extremity embolic arterial occlusion. METHODS: Six patients were referred to the echocardiography laboratory for evaluation of a source of peripheral arterial embolism. The transthoracic echocardiogram was extended to include longitudinal and transverse images of the abdominal aorta. Additional investigations included abdominal ultrasound (6 patients), computed tomography (2 patients), angiography (2 patients), and transesophageal echocardiography (4 patients). RESULTS: Six patients (4 men, 2 women, aged 46 to 79 years) presented with a blue toe syndrome consistent with atheroembolism. During transthoracic echocardiography with examination of the abdominal aorta, all were found to have significant atherosclerotic disease of the abdominal aorta with one or more mobile components. This finding had a significant impact on treatment of each patient. Surgical resection of the involved portion of the abdominal aorta in one patient demonstrated an ulcerated atheroma with overlying thrombus. CONCLUSION: In patients with lower extremity embolic arterial occlusion, evaluation of the abdominal aorta during transthoracic echocardiography should be a routine extension of the echocardiographic examination. The finding of mobile thrombi in the abdominal aorta identifies a potential source of embolism for which effective treatment exists.
Aged↗
Personal ultrasound imager: abdominal aortic aneurysm screening.
BACKGROUND: Miniaturized ultrasonographic machines (2.5-MHz curved-array transducer connected to a compact 2.6-kg console), termed personal ultrasound imagers (PUIs), may enable detection of occult abdominal aortic aneurysms (AAAs). OBJECTIVES: Our goals were to determine whether a PUI is capable of screening for AAAs and to compare the results with an established screening examination with standard echocardiography (SE). METHODS: One hundred twenty-five patients (aged >70 years) with hypertension who were referred for transthoracic echocardiography were enrolled. After SE, a focused screening with a PUI examination was performed by a blinded sonographer. An AAA was defined as a focal enlargement of the aorta >30 mm. Results and the length of time to image the aorta were compared for both tests. RESULTS: We studied 64 men and 61 women (aged 76.8 +/- 5 years; mean blood pressures: systolic 145.7 +/- 18 and diastolic 78.6 +/- 10; body surface area 1.9 +/- 0.2 m(2)). The mean time for SE was 2.9 +/- 1.5 minutes and for the PUI examination was 4.6 +/- 2.3 minutes. By using SE as the gold standard, the sensitivity and specificity of the PUI were 91% and 96%, respectively. The positive predictive value of the PUI was 71%, and the negative predictive value was 99%. CONCLUSION: A PUI can be used to screen for occult AAAs as an extension of the physical examination. Results are comparable to an established screening strategy that uses more expensive, nonportable echocardiographic equipment.
Aged↗
Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography and carotid ultrasonography: the SPARC study. Stroke Prevention: Assessment of Risk in a Community.
OBJECTIVE: The SPARC (Stroke Prevention: Assessment of Risk in a Community) study was designed to identify risk factors for stroke and cardiovascular disease using transesophageal echocardiography and carotid ultrasonography. This protocol was undertaken to establish a cohort in which putative risk factors for stroke were identified so that subsequent follow-up could discern the roles these risk factors play in stroke incidence. SUBJECTS AND METHODS: This was a prospective, population-based study. A randomly selected cohort comprised 1475 Olmsted County, Minnesota, residents aged 45 years or older, of whom 588 agreed to participate. Transesophageal echocardiography and carotid ultrasonography were used for evaluation of the subjects. Prevalences of various cardiovascular and cerebrovascular conditions were determined. RESULTS: Transesophageal echocardiography was successfully completed in 581 subjects. The prevalence (+/-SE) of patent foramen ovale was 25.6% (+/-1.9%), and that of atrial septal aneurysm was 2.2% (+/-0.6%). The prevalence of aortic atherosclerosis increased with age and was most common in the descending aorta, particularly in subjects 75 to 84 years old. The prevalence of strands on native valve was 46.4% (+/-2.2%). Carotid ultrasonography data for 567 participants revealed minimal atherosclerotic disease. Most subjects had minimal or mild carotid occlusive disease. The prevalence of moderate (50%-79%) and severe (80%-99%) stenosis was 7.7% (+/-1.1%) and 0.3% (+/-0.2 %), respectively. CONCLUSIONS: This prospective study defines the prevalence of multiple potential cardiovascular and cerebrovascular risk factors, providing population-based data for ongoing follow-up of the risk of stroke.
Adult↗
Internal mammary artery: 100% visualization with new ultrasound technology.
We report our experience in visualizing the internal mammary artery (IMA) with new enhanced Doppler technology. Twenty-three patients without previous coronary artery bypass grafting formed the study group. Bilateral transthoracic two-dimensional and color flow Doppler IMA images were acquired from multiple intercostal spaces with a prototype ultrasound machine equipped with coherent beam formation technology. In all patients, the IMA was followed from its origin for an average of 15 cm. To our knowledge, a high rate of direct visualization (100%) of the IMA has not been reported previously. Noninvasive ultrasound assessment of the IMA may reduce the need for invasive preoperative testing for patency and length and allow postoperative assessment of coronary artery flow reserve.
Adult↗
Dobutamine effect on ankle-brachial pressure index in patients with peripheral arterial occlusive disease. New noninvasive test for evaluation of peripheral circulation?
BACKGROUND: This study was designed to evaluate the effect of short-term administration of graded dose of dobutamine on the circulation of the lower limbs in the patients with symptomatic peripheral arterial occlusive disease. METHODS: An ankle-brachial pressure index (ABI) was determined at the time of dobutamine stress echocardiography by measuring systolic pressure over the brachial artery and right dorsalis pedis artery using continuous-wave Doppler instrument. Setting. The study was conducted on all patients who had dobutamine stress echocardiography ordered by their referring physicians and performed in the Echocardiography Laboratory of the Mayo Clinic. Patients. All patients scheduled for dobutamine stress echocardiography were the subject of this study unless they had rigid vessels defined as ABI > 1.5, were on beta-blockers or did not agree to participate in the study. 20 patients, mean age 67 +/- 9 years (9 men and 11 women) without peripheral occlusive arterial disease and resting ABI > or = 1.0 (group A), and 18 patients, mean age 71 +/- 10 years (11 men and 7 women) with the evidence of peripheral occlusive arterial disease and ABI < 1.0 were examined. Measures. ABI was measured just prior to starting the dobutamine infusion, and then at the third minute of each increment in dobutamine dosage. RESULTS: In control group patients ABI rises at 5-10 micrograms/kg/min of dobutamine infusion and at higher doses (20-50 micrograms/kg/min) drops back to the baseline values. In the patients with peripheral arterial occlusive disease low doses of dobutamine do not increase ABI, but higher doses cause decrease of pressure index from 0.6 to 0.3. There was no incidence of ischemic pain or any other kind of discomfort in the lower extremities. CONCLUSIONS: Low doses of dobutamine have no decremental effect on peripheral circulation. High doses of dobutamine cause a profound decrease of blood pressure in the lower limbs of patients with peripheral occlusive arterial disease, and the extent of decrease was proportional to the degree of ischemia. Peripheral blood pressure changes registered in the study over dorsalis pedis artery at the time of dobutamine infusion resemble those that occurred at the time of exercise-walking test. ABI measurement at the time of dobutamine echocardiography might be a useful test for the evaluation of peripheral circulation. Further studies are necessary for the assessment of a clinical usefulness of dobutamine-ankle-brachial test.
Adult↗
Screening for abdominal aortic aneurysm during transthoracic echocardiography in a hypertensive patient population.
This study was undertaken to determine the utility of transthoracic echocardiography as a screening test for occult abdominal aortic aneurysm in hypertensive patients older than 50 years of age. Longitudinal and transverse images of the abdominal aorta were obtained during the subcostal portion of the transthoracic echocardiogram. Abdominal aortic aneurysm was defined as an abdominal aortic dimension (antero-posterior or lateral) > or = 3.0 cm. Exclusion criteria included prior abdominal aortic aneurysm repair, known abdominal aortic aneurysm, or inadequate images of the abdominal aorta (nine patients). Two hundred patients (107 men, 93 women; mean age 71 years, range 51 to 92 years) met the study inclusion criteria. An occult abdominal aortic aneurysm was identified in 13 patients (6.5%). Sixty-nine percent of the abdominal aortic aneurysm patients were men, with a mean age of 73 years and a mean duration of hypertension of 11 years. Seventy-seven percent had a history of tobacco use, and 15% had a positive family history of abdominal aortic aneurysm. All aneurysms were infrarenal in location, with abdominal aortic aneurysm diameter ranging from 3.0 to 5.2 cm (mean 3.9 cm). Laminated thrombus was present in six patients (46%), and in one patient a right common iliac artery aneurysm was also detected. Imaging of the abdominal aorta during transthoracic echocardiography required an average of 6.7 minutes (range 4 to 10 minutes). In conclusion, the abdominal aorta could be accurately imaged in the majority of patients (96%) undergoing transthoracic echocardiography in this study. The incidence of occult abdominal aortic aneurysm in hypertensive patients older than 50 years of age is significant (6.5%). Screening for occult abdominal aortic aneurysm in this patient population should be a routine extension of the transthoracic echocardiogram.
Age Factors↗
The premortem recognition of systemic senile amyloidosis with cardiac involvement.
PURPOSE: To recognize systemic senile amyloidosis involving the heart and to determine outcome. PATIENTS AND METHODS: All patients with the diagnosis of amyloidosis at the Mayo Clinic from January 1, 1984 through May 1, 1992, were reviewed. Amyloid was confirmed histologically by sulfated alcian blue and alkaline Congo red staining. The labeled streptavidin-biotin immunoperoxidase method was used with antisera against A kappa, A lambda, AA, transthyretin, and beta 2-microglobulin. Anti-P-component and antisera to albumin were used as controls. Chest radiographs, electrocardiograms, transthoracic echocardiograms, and cardiac catheterization data of all patients were reviewed. Serum and urine were examined with immunoelectrophoresis and immunofixation for the presence of a monoclonal protein. Lymphocyte DNA was examined for transthyretin mutations associated with familial amyloidosis. RESULTS: We identified 18 patients with myocardial tissue that stained positive for amyloid with sulfated alcian blue and Congo red and with transthyretin antisera. Congestive heart failure was present at diagnosis in 17 of the 18 patients. Atrial fibrillation was found in 11 patients. No monoclonal protein was found in the serum or urine. The echocardiographic findings were consistent with infiltrative cardiomyopathy due to amyloidosis in 16 patients. Right heart pressures were elevated in all 7 patients who had right-side heart catheterization. No transthyretin mutations were found in the leukocyte DNA from 12 patients. The actuarial median survival was 5 years; in contrast, the median survival was 5.4 months in 147 patients with primary amyloidosis (AL) who presented with congestive heart failure. CONCLUSION: Patients with cardiac amyloid and no monoclonal protein in the serum or urine must have immunohistochemical staining for kappa and lambda light chains and transthyretin to distinguish between systemic senile amyloidosis, familial amyloidosis, and AL. Patients with systemic senile amyloidosis should not be treated with alkylating agents. Their survival is much longer than that of patients with AL (60 versus 5.4 months).
Age Factors↗
64-year-old woman with chest pain and presyncope.
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Aged↗
79-year-old woman with blue toes.
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Aged↗
Occlusive arterial disease of the hand due to repetitive blunt trauma: a review with illustrative cases.
OBJECTIVE: to increase clinical awareness of the role of repetitive blunt trauma, often occupational, in the development of occlusive arterial disease of the hand. STUDY DESIGN: illustrative cases are presented to emphasize the varied etiology and clinical features of occlusive arterial disease of the hand resulting from repetitive blunt trauma and an historical review of the literature is presented. RESULTS: Occlusive arterial disease of the hand due to repetitive blunt trauma is a common but often preventable disorder. The superficial location of many of the arteries of the hands and digits plus their close proximity to the bones of the hand makes them uniquely susceptible to injury from repetitive blunt trauma. An ever increasing number of occupations and leisure activities have been causally related to occlusive arterial disease of the hand. The diagnosis of occupational occlusive arterial disease due to blunt trauma is suggested by eliciting a history of repetitive blunt trauma to the hand in a patient with symptoms and/or signs of digital ischemia. The dominant hand is most commonly involved, but the non-dominant hand or both hands are affected in certain occupations. Possible predisposing or aggravating factors include tobacco use and working in a cold environment. The diagnosis of occlusive arterial disease confined to the hand or digits is confirmed by non-invasive studies in the vascular laboratory and demonstrated by arteriography. Conservative measures and protection of the hand from further trauma is sufficient for most patients, with surgical therapy being reserved for patients refractory to medical therapy or those with more severe ischemia. CONCLUSION: occlusive arterial disease of the hand may be more common than formerly thought and is often preventable by the proper use of hand tools or instruments and hand protection. This is another type of occlusive arterial disease in which tobacco may be a predisposing or aggravating factor.
Adult↗
Clinical features and differential diagnosis of aortic dissection: experience with 236 cases (1980 through 1990).
Acute aortic dissection is the most common fatal condition that involves the aorta; nevertheless, despite major advances in noninvasive diagnosis, the correct antemortem diagnosis is made in less than half the cases. To promote continued improvement in the prompt recognition of aortic dissection, we present a review of the Mayo Clinic experience with 235 patients who had 236 substantiated aortic dissections. At the time of initial assessment, 158 patients (67%) had acute and 78 patients (33%) had chronic aortic dissection. Hypertension was the most common predisposing factor (78% of patients overall). The acute onset of severe chest pain was the most common initial complaint (74%), but 33 patients (15%) had painless aortic dissection and abnormal chest roentgenographic findings. Less common manifestations included congestive heart failure, syncope, cerebrovascular accident, shock, paraplegia, and lower extremity ischemia. The initial clinical impression was aortic dissection in 62% of patients overall. In 17 patients (28%), the correct diagnosis was not made before postmortem examination. Although the clinical features of aortic dissection have gained wider appreciation, the diagnosis still remains unsuspected in a substantial number of patients. In a patient who has a catastrophic illness and unexplained symptoms that could be of vascular origin, especially in the presence of chest pain, aortic dissection should always be included in the differential diagnosis.
Acute Disease↗
Venous complications after insertion of a transvenous pacemaker.
We reviewed the incidence, clinical features, current diagnostic evaluations, and treatments of venous complications that can occur after implantation of a transvenous pacemaker. Of the approximately 80 published articles on the potential venous complications after implantation of a permanent transvenous pacemaker, we selected 63 that addressed the clinical features, diagnosis, and treatment of pacemaker lead-induced venous thrombosis, which occurs in approximately 30 to 45% of patients early or late after implantation of a transvenous pacemaker. Most patients with chronic deep venous thrombosis remain asymptomatic because of the development of an adequate venous collateral circulation. Clinical features of pacemaker lead-induced deep venous thrombosis, although rare, are easily recognized. They should be sought routinely during follow-up of all patients with transvenous pacemaker leads because venous obstruction can interfere with intravenously administered therapy, monitoring of central venous pressure, and revision of a pacemaker lead. Acute deep venous thrombosis is likely to be symptomatic. Early recognition and treatment of acute deep venous thrombosis may help to decrease the potential morbidity and mortality. The definitive diagnosis of pacemaker lead-induced venous thrombosis necessitates contrast-enhanced or digital subtraction venography. Management includes anticoagulation, thrombolytic therapy, surgical intervention, and, recently, percutaneous transluminal balloon venoplasty and depends on the duration, extent, and site of venous occlusion as well as the accompanying symptoms.
Cardiac Pacing, Artificial↗
Venous obstruction due to permanent transvenous pacemaker electrodes: treatment with percutaneous transluminal balloon venoplasty.
Transvenous placement of permanent pacemaker leads is currently the most common method for permanent cardiac pacing. Venous abnormalities, in particular venous stenosis or thrombosis (or both) frequently have been described, although most patients remain asymptomatic because of the development of an adequate venous collateral circulation. Venous obstruction often first becomes apparent during pacemaker lead revision, when difficulty passing the new pacing lead is encountered. In this report, we present two cases of venous stenosis and thrombosis due to permanent transvenous pacemaker electrodes and the use of percutaneous transluminal balloon venoplasty to relieve the venous obstruction.
Aged↗
Facilitation of the subclavian-introducer technique with contrast venography.
The subclavian-introducer technique is a rapid and easily performed method of obtaining venous access for implanting permanent pacemaker electrodes. Although this technique has facilitated the participation of nonsurgeons in pacemaker implantation, the potential for complications is increased over the venous cutdown approach. This is particularly true in difficult cases, such as those with prior lead implants, venous thrombosis, or anomalous venous return. This article describes the use of contrast venography for facilitating an otherwise "blind" subclavian venipuncture. This method should make use of the subclavian-introducer technique safer.
Catheterization, Peripheral↗