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PubMed2006

The prevalence of thrombophilia in patients with symptomatic peripheral vascular disease.

BACKGROUND: The aim of this prospective study was to establish the prevalence of thrombophilia and hyperhomocysteinaemia using a comprehensive screen in patients with peripheral vascular disease. METHODS: A total of 150 patients with peripheral vascular disease (with an ankle brachial pressure index of less than 0.8) underwent thrombophilia screening (protein C and protein S, antithrombin, lupus anticoagulant, activated protein C resistance and factor V Leiden and prothrombin mutations). Fasting homocysteine assays were also performed. RESULTS: A thrombophilia defect was found in 41 patients (27.3 per cent). The commonest was protein S deficiency, found in 17 patients (11.3 per cent). Others included factor V Leiden mutation, found in 10 (6.7 per cent) and protein C deficiency, found in six (4.0 per cent). Lupus anticoagulant and prothrombin mutation were both found in six (4.0 per cent). One patient had an antithrombin deficiency. Only the presence of critical ischaemia was associated with a positive thrombophilia screen on single variable analysis (P = 0.03). Hyperhomocysteinaemia was present in over a third of the study group (37.3 per cent): 45 defined as moderate and 11 as intermediate. CONCLUSION: A quarter of patients with peripheral vascular disease had evidence of thrombophilia, and a third had hyperhomocysteinaemia.

Aged↗
PubMed1990

Perioperative and long-term prognostic value of intravenous dipyridamole thallium scintigraphy in patients with peripheral vascular disease.

The prognostic value of long-term risk stratification of patients with peripheral vascular disease who undergo intravenous dipyridamole thallium scintigraphy has not been well studied. We screened 131 patients with peripheral vascular disease who underwent intravenous dipyridamole thallium testing to determine cardiac event rates over an average follow-up of 18 +/- 10 months. Of the 131 patients, 111 subsequently had peripheral vascular surgery. The patients with abnormal thallium scans after dipyridamole had a significantly higher risk of death or myocardial infarction, both in the perioperative phase (7% versus 0%; p less than 0.001) and at late follow-up (17% versus 6%; p less than 0.01). The risk of a cardiac event was two-fold greater when a reversible as compared to a fixed thallium defect was present. Multivariate analysis selected the number of thallium segments with perfusion defects, prior history of angina pectoris, and chest pain during dipyridamole testing as perioperative predictors of a cardiac event. A reversible thallium defect was the only predictor of death or nonfatal myocardial infarction during late follow-up. Thus intravenous dipyridamole thallium scintigraphy is a useful noninvasive test for risk stratification of patients before peripheral vascular surgery and provides prognostic information as to the risk of a cardiac event in the 2-year period after the test. A reversible thallium defect is associated with a significant increased risk and would indicate that coronary angiography should be considered and preoperative coronary revascularization.

Aged↗
PubMed2000

Arterial pulse wave velocity and risk factors for peripheral vascular disease.

Non-invasive measurement of arterial pulse wave velocity (PWV) is used to diagnose peripheral vascular disease. We examined the relationship between PWV and risk factors related to peripheral vascular disease [body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), serum total cholesterol (TC), high-density lipoprotein-cholesterol (HDL-C), atherogenic index (AI) and blood glucose (GLU)] in 45 healthy male volunteers, aged 25-85 years. The correlation coefficient of PWV with age was r = 0.46, and the correlation coefficients of PWV with DBP, AI and GLU were r = 0.71, 0.56, and 0.22, respectively (P < 0.05). Multiple linear regression analysis revealed that 67% of the variance in PWV could be accounted for by these three variables. The relative contributions of DBP, AI and GLU to PWV were 66%, 26% and 8%, respectively. To test the applicability of PWV for clinical use, a multiple regression equation of PWV derived from these three variables was then applied to male patients with hypertension (n = 53), hyperlipidaemia (n = 35) or hyperglycaemia (n = 39). The results suggest that the multiple regression equation of PWV is an indicator that discriminates between these patient categories and healthy men.

Adult↗
PubMed1985

Cutaneous delayed hypersensitivity, T cell subsets, and IL-2 secretion in patients with peripheral vascular disease.

To determine whether anergy in patients with peripheral vascular disease is related to an abnormality of their T cells, the distribution of T-cell subsets and monocytes in peripheral blood was studied in relation to the delayed hypersensitivity response following the intradermal injection of 7 recall antigens. Positive correlation coefficients were observed between either the sum of the induration at 48 hr or the number of antigens giving a positive response and the percentage of total T cells (OKT 3) and helper T cells (OKT 4). The percentages of suppressor/cytotoxic T cells (OKT 8) and monocytes (OKM 1) showed no correlation with skin reactivity to the recall antigens. In vitro secretion of IL-2 by purified T cells was similar in anergic patients and in patients with normal delayed hypersensitivity responses. Addition of IL-2 to unstimulated T cells or T cells stimulated in vitro with either tetanus toxoid or PPD sometimes potentiated incorporation of 3H-thymidine into the cells after 6 days of culture.

Adult↗
PubMed2006

Does arsenic exposure increase the risk of development of peripheral vascular diseases in humans?

Arsenic has been well documented as a major risk factor in the development of blackfoot disease (BFD), a unique peripheral vascular disease (PVD) endemic to the southwestern coast of Taiwan, where residents imbibed artesian well water containing excessive amounts of arsenic for more than 50 yr. Long-term arsenic exposure was also reported to be associated with mortality attributed to PVD. A tap-water supply system was implemented in the early 1960s in the BFD endemic areas. Artesian well water was no longer used for drinking and cooking after the mid-1970s. The objective of this study was to examine whether mortality attributed to PVD decreased after the consumption of artesian well water containing high concentrations of arsenic ceased and, if so, when the reduction occurred. Standardized mortality ratios (SMRs) for PVD were calculated for the BFD endemic area for the years 1971-2003. Cumulative-sum techniques were used to detect the occurrence of changes in the SMRs. Data showed that mortality due to PVD declined gradually for approximately 25 to 27 yr following cessation of consumption of this arsenic artesian well water. Based on the reversibility criterion, the association between arsenic exposure and PVD-attributed mortality is likely to be causal.

Arsenic Poisoning↗
PubMed1996

Carotid artery stenosis in peripheral vascular disease.

PURPOSE: The goal of the study was to assess the prevalence and severity of symptomatic and asymptomatic carotid artery disease in patients with peripheral vascular disease (PVD). METHODS: Consecutive patients with clinically and Doppler scanning-proven PVD (category 1 or greater) underwent prospective screening for the presence of carotid atherosclerosis with color-coded duplex ultrasonography. Preexisting risk factors were recorded with a standard questionnaire and included sex, age, diabetes mellitus, history of smoking, hypertension, prior stroke/transient ischemic attacks, and coronary artery disease. RESULTS: Three hundred seventy-three consecutive patients were studied over 2 years. The mean age of the patients was 70 +/- 10 years; there were 223 (60%) men and 150 (40%) women; 71% of the patients had a history of smoking, 47% had coronary artery disease, 43% had hypertension, and 21% had diabetes mellitus. Two hundred eleven (57%) patients had 30% or greater carotid artery stenosis detected by carotid artery duplex scanning. Sixty-seven (32%) of these had symptoms of ischemic cerebral events, of whom 22 had potentially operable carotid artery stenoses (70% to 99%), whereas 72 of the 144 symptom-free patients had 60% to 99% stenosis. An additional 34 patients would be eligible candidates for the ongoing carotid endarterectomy trials (North American Symptomatic Carotid Endarterectomy Trial and European Carotid Surgery Trial). Although all the risk factors were associated significantly with PVD and carotid artery disease (p < 0.002), male sex and prior stroke/transient ischemic attack were the strongest predictors. CONCLUSIONS: Routine carotid ultrasound screening of 373 consecutive patients with category I or greater PVD revealed that 22 patients with symptoms and 72 symptom-free patients were potential surgical candidates, representing 25% of the study cohort. An additional 34 patients were potential candidates for enrollment into the North American Symptomatic Carotid Endarterectomy Trial and European Carotid Surgery Trial.

Age Factors↗
PubMed1993

The potential benefit of pre-operative assessment of amputation wound healing potential in peripheral vascular disease.

Choosing the most distal amputation level that will heal is difficult in patients with peripheral vascular disease. From 1984 to 1988, 965 patients underwent 1,563 amputations for lower limb peripheral vascular disease at King Edward VIII Hospital, Durban. The primary amputation revision rate was 51% with a mortality rate of 23.1%. Random pre-operative assessment of amputation wound healing potential using a transcutaneous oxygen pressure index was investigated over the 4-year period, 1987-1990. This was responsible for a reduction in the amputation revision rate to 8.2% in patients tested.

Amputation, Surgical↗
PubMed1989

Arm exercise testing with myocardial scintigraphy in asymptomatic patients with peripheral vascular disease.

Arm exercise with myocardial scintigraphy and oxygen consumption determinations was performed by 33 men with peripheral vascular disease, 40 to 74 years of age (group 2). None had evidence of coronary disease. Nineteen age-matched male control subjects (group 1) were also tested to determine the normal endurance and oxygen consumption during arm exercise in their age group and to compare the results with those obtained during a standard treadmill performance. The maximal heart rate, systolic blood pressure, pressure rate product, and oxygen consumption were all significantly lower for arm than for leg exercise. However, there was good correlation between all these parameters for both types of exertion. The maximal heart rate, work load and oxygen consumption were greater for group 1 subjects than in patients with peripheral vascular disease despite similar activity status. None of the group 1 subjects had abnormal arm exercise ECGs, while six members of group 2 had ST segment changes. Thallium-201 scintigraphy performed in the latter group demonstrated perfusion defects in 25 patients. After nine to 29 months of follow-up, three patients who had abnormal tests developed angina and one of them required coronary bypass surgery. Arm exercise with myocardial scintigraphy may be an effective method of detecting occult ischemia in patients with peripheral vascular disease. Those with good exercise tolerance and no electrocardiographic changes or 201T1 defects are probably at lower risk for the development of cardiac complications, while those who develop abnormalities at low exercise levels may be candidates for invasive studies.

Adult↗
PubMed1985

Thrombocytopenia and lupus-like anticoagulant in a patient with peripheral vascular disease: response to infusion of prostacyclin.

A 46 year old man with intermittent claudication due to severe peripheral vascular disease had a circulating lupus like anticoagulant (LLAC), thrombocytopenia (79 X 109/1), markedly reduced platelet survival and a normal bone marrow. He was treated with intravenous prostacyclin (PGI2) infusions which resulted in improvement of the patient's exercise tolerance and normalisation of his platelet count (300 X 109/1) and platelet aggregation could then be assessed. The platelets were markedly hyperaggregable and generated supranormal quantities of thromboxane A2. A diagnosis of consumptive thrombocytopenia secondary to peripheral vascular disease and platelet hyperaggregability was made. Despite therapy with aspirin and dipyridamole, gradual and progressive reduction in platelet count followed and his exercise tolerance declined over the next three months. Immunoglobulin prepared from the patient's serum did not inhibit vascular PGI2 synthesis in vitro. To our knowledge this is the first reported case of consumptive thrombocytopenia due to severe peripheral vascular disease and platelet hyperaggregability. PGI2 administration caused a transient resolution of these features which was not sustained by aspirin and dipyridamole.

Arteriosclerosis Obliterans↗
PubMedDate not supplied

Metabolic approach to the diagnosis and treatment of atherosclerotic peripheral vascular disease.

Metabolic and clinical peculiarities of patients with peripheral vascular disease (PVD) were evaluated in two studies. In the first study lipid and lipoprotein composition of 20 patients with PVD were examined. Twelve of these patients were normolipidemic, the other 8 hypertriglyceridemic. Ten normolipidemic and ten hyperlipidemic age-matched subjects served as controls. High density lipoprotein cholesterol (HDL-C) levels were markedly reduced in the hypertriglyceridemic, both with (35.1 +/- 5.0 mg/dl) and without (36.2 +/- 11.7 mg/dl) PVD as compared to the normolipidemic patients (47.0 +/- 6.3 mg/dl) and controls (48.1 +/- 10 mg/dl). All the PVD patients showed an increased apolipoprotein B content in the very low density lipoproteins (VLDL) as compared to controls (p less than 0.001). A significant correlation between VLDL-cholesterol and apo B levels was detected in both groups; however, two distinct populations could be clearly separated (slopes of the regression lines: PVD patients = 0.350; controls = 0.215, p less than 0.0001). These data suggest a possible discriminatory power of VLDL-apo B levels in PVD patients independent of other metabolic parameters. In the second study, the clinical activity of metformin (N, N-dimethylbiguanide) a widely used antidiabetic agent, on arterial blood flow was evaluated in 15 patients with PVD. Flow was determined by quantitative strain-gauge plethysmography during a cross-over trial, comparing 6 months of drug and placebo administration. Metformin (850 mg tid) significantly increased arterial flow after a standardized ischemia in both sequences. In spite of the minimal changes of plasma lipid levels during metformin, a highly significant increase of HDL-C levels (+8.3% during the whole treatment) was demonstrated. Plasma levels of isoprotein AI-1 were also raised during the metformin period. Although the mechanism/s of the beneficial effects of metformin on flow cannot, at present be defined, the reported results underline the significant therapeutic potential of this metabolic drug treatment in PVD.

Adult↗
PubMedDate not supplied

Optimized diagnostic angiography in high-risk patients with severe peripheral vascular disease.

Conventional arteriography remains the usual method for preoperative assessment of severe peripheral vascular disease (PVD). Unfortunately, many peripheral arteriograms are still performed with a suboptimal technique, which can cause significant diagnostic errors in patients with severe PVD. A suboptimal technique may be due to poor collimation (causing incorrect exposure and incorrect gray scale), excessive patient-film distance (magnification unsharpness), inadequate volume or density of contrast material, poor contrast resolution (screen-film arteriography), nonselective injection, patient movement, and pressure from restraints or incorrect patient position (failure to profile lesions, pseudo-occlusion from external pressure or plantar flexion). The technique of selective digital subtraction arteriography (DSA) allows one to avoid these errors. The superior contrast resolution of DSA allows use of lower concentrations of contrast material. Selective injection into the external iliac artery allows proper positioning and improves image quality. Demonstration of distal vessels is best achieved by using biplane arteriography. For patients with severe resting ischemia, especially those with diabetes, high-quality selective DSA is essential to ensure that all distal vessels suitable for distal bypass grafting are identified. When properly performed, selective DSA remains the investigation of choice for reliably demonstrating arterial anatomy in high-risk patients with severe PVD.

Angiography, Digital Subtraction↗
PubMed1994

To what extent does peripheral vascular disease and hypertension predict renal artery stenosis?

The incidence of renal artery stenosis (RAS) was prospectively evaluated by aortofemoral angiography in 100 patients with peripheral vascular disease (PVD) to find whether RAS was a more common finding in hypertensive than in normotensive patients. For a possible association with RAS, risk factors, clinical and angiographical variables were evaluated. Nephrotoxicity of the contrast medium Iohexol was elucidated. A follow-up of six month was performed in patients with severe stenosis or total occlusion of the renal arteries. Of the 49 patients with a renal artery lesion 26.5% were normotensive and 73.5% hypertensive. Hypertension was significantly correlated to RAS. Reconstructive vascular procedures were during the follow-up performed in 47.3% of the patients with severe RAS or occluded renal arteries, two patients underwent a renal artery revascularization, none of them got a postoperative blood pressure decrease. Hypertension in patients with peripheral vascular disease is predictive for renal artery stenosis and a possible renovascular hypertension should be evaluated. Surgery for renal artery stenosis in peripheral vascular diseased patients should, however, probably be performed firstly to reduce the risk for occlusion. The effect on the blood pressure can not be predicted without a more careful analysis that the blood pressure is renin-dependent. Iohexol showed low nephrotoxicity, also in patients with renal artery disease.

Aged↗
PubMedDate not supplied

Prevalence of symptomatic diastolic heart failure in patients hospitalized with cerebral or peripheral vascular disease.

The authors sought to determine the prevalence of diastolic heart failure (DHF) in patients hospitalized with their first stroke, transient ischemic attack, or new onset of peripheral vascular disease. A total of 216 prospective consecutive stroke, transient ischemic attack, and peripheral vascular disease patients (vascular group) were identified at their first noncardiac presentation to a hospital and compared with 164 age-matched control patients (nonvascular group). DHF was clinically defined as the presence of left ventricular ejection fraction>or=45% on echocardiography. DHF occurred in 40% and 73% of vascular and control patients, respectively, with symptomatic heart failure. Overall, it was found in 12% of vascular (10% of stroke/transient ischemic attack, 16% of peripheral vascular disease) and 11% of control patients. Advancing age and female gender were independently associated with the presence of DHF in vascular patients (p<0.05). DHF is found in a similar percentage of vascular and nonvascular patients. Symptomatic DHF is less common than systolic heart failure among vascular disease patients with heart failure. In contrast, symptomatic DHF is found in three times as many age-matched control heart failure patients without clinical vascular disease.

Aged↗
PubMed1995

Pain, pills, and possibilities: drug therapy in peripheral vascular disease.

Currently, pharmacologic therapy offers no cures for the patient with vascular disease. Drugs are available, however, to prevent or delay the end organ damage of vascular disease, to keep vessels patent as long as possible, and to provide some relief from the pain associated with vascular disease and cell damage. In this article, the author reviews the drugs used to manage hypertension--diuretics, beta blockers, alpha adrenergic blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers, antiadrenergic drugs, and nitroprusside; and drugs used to maintain vessel patency in peripheral vascular disease--peripheral vasodilators and anticoagulants; and reviews one regimen for dealing with the chronic pain of vascular disease--narcotics and tricyclic antidepressants.

Drug Monitoring↗
PubMed1986

The impact of percutaneous transluminal angioplasty on the management of peripheral vascular disease.

Percutaneous transluminal angioplasty is a well established technique with wide application, but its place in the overall management of peripheral vascular disease is not well defined. This study compares similar groups of patients with peripheral vascular disease in 1981 and 1984, before and after the introduction of the technique to a district general hospital. More patients are now being investigated and treated and this is almost entirely due to the availability of angioplasty. The rates for surgery have not changed. Percutaneous transluminal angioplasty should therefore be seen as a new and separate form of treatment for peripheral vascular disease, not necessarily influencing or replacing surgery, and requiring its own allocation of resources in accordance with the increase in the level of care afforded by the technique.

Aged↗