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PubMed1993

Beneficial effects of a serine protease inhibitor in peripheral vascular disease.

Kallikrein, a serine protease known to generate bradykinin (a vasodilating peptide) in alkaline conditions, also generates angiotensin II (a vasoconstricting peptide) in weak acidic conditions. Based on this previous observation, the present study was performed to determine whether ischemic muscle tissue, in which the regional pH must decrease, produces angiotensin II by kallikrein or a similar enzyme, and whether nafamostat (NAF), a serine protease inhibitor, improves local hemodynamics under ischemic conditions caused by exercise in patients with ischemic peripheral vascular disease. NAF was administered intravenously to 20 patients with peripheral vascular disease. Lower-limb thermograms and blood flow were measured before and after exercise. Femoral venous blood of affected limbs was obtained to measure viscosity and humoral variables (i.e., pH, lactate, angiotensin II and bradykinin). Walking distance and subjective symptoms were also recorded. As a control, the same patients repeated this test with saline infusion on a separate day. NAF significantly increased maximal walking distance, improved subjective symptoms during exercise, and attenuated exercise-induced venous lactate and blood viscosity increases, and pH reduction. The blood viscosity increase correlated with the lactate increase. Pretreatment with NAF also resulted in a higher lower-limb skin temperature, and a greater increase of blood flow in the lower limbs after exercise than did pretreatment with saline. The results suggest that kallikrein-like serine protease may exacerbate ischemic symptoms. Changes in plasma bradykinin and angiotensin II in the femoral vein were not detectable, probably because of the lower levels of these peptides in the peripheral circulation.

Aged↗
PubMed2006

Revascularization for peripheral vascular disease in Aboriginal and non-Aboriginal patients.

BACKGROUND: Canadian Aboriginal subjects have a higher prevalence of diabetes, renal disease, and lower extremity amputation than non-Aboriginal subjects. However, limited information is available about patient outcomes for arterial bypass surgery in Canadian Aboriginal compared with non-Aboriginal subjects. METHODS: A retrospective study of all patients undergoing revascularization for peripheral vascular disease at a tertiary care referral center was performed. RESULTS: A total of 828 procedures were performed on 678 patients between 1995 and 2002: 108 (13%) procedures on 84 (12%) Aboriginal patients and 720 (87%) procedures on 594 (88%) non-Aboriginal patients. Aboriginal patients had a higher prevalence of diabetes, chronic renal failure, and end-stage renal disease than non-Aboriginal patients. Aboriginal patients presented with more serious complications (gangrene [Aboriginal, 63 [58%] of 108 patients; non-Aboriginal, 112 [16%] of 720 patients; P < .0001] and nonhealing ulcer [Aboriginal, 29 [27%] of 108 patients; non-Aboriginal, 131 [18%] of 720 patients; P < .05]) and required urgent or emergency revascularization (Aboriginal, 47 [49%] of 95 patients; non-Aboriginal, 228 [36%] of 634 patients; P < .02) more frequently than non-Aboriginal patients. The 60-month patient mortality was similar for both groups (Aboriginal, 20 [24%] of 84 patients; non-Aboriginal, 160 [27%] of 594 patients; not significant), but Aboriginal patients had loss of limb more frequently (Aboriginal, 19 [18%] of 108 patients; non-Aboriginal, 62 [9%] of 720 patients; P < .0001) and had loss of primary graft patency more frequently (Aboriginal, 39 [36%] of 108 patients; non-Aboriginal, 155 [22%] of 720 patients; P < .0001) than non-Aboriginal patients. CONCLUSIONS: Canadian Aboriginal subjects had worse outcomes with revascularization than non-Aboriginal subjects, but ethnicity and diabetes were not independent risk factors for poor outcome. Multivariate analysis showed that the poor outcomes in mortality, limb salvage, and primary graft patency among Aboriginal patients undergoing revascularization may be attributed to renal disease and a more advanced mode of presentation of peripheral vascular disease complications at the time of intervention.

Age Distribution↗
PubMed2001

Ocular and orbital blood flow velocity in patients with peripheral vascular disease and diabetes treated with intravenous prostaglandin E1.

The purpose of this study was to evaluate the effect of intravenous prostaglandin E1 (PGE1) on the flow velocity of the ophthalmic artery and the central retinal artery in patients with peripheral vascular disease manifested by intermittent claudication. The flow velocity of these vessels is frequently decreased in vascular patients. Since these patients were already being treated with PGE1 for their intermittent claudication, the authors wanted to evaluate the effect on the flow velocity of the ocular vessels as well. A randomized 21-week study of two groups of vascular patients was performed. The first group had intermittent claudication. The second group had intermittent claudication and were also diabetics. Both groups were treated with intravenous PGE1 for their intermittent claudication. Using the color Doppler, the flow velocities of the ophthalmic artery and central retinal artery were measured before and after the intravenous treatment. Before treatment, the flow velocity of the ophthalmic artery and the central retinal artery was decreased when compared to that in the normals. After treatment, there was a significant increase in the systolic and diastolic phases of the flow velocity in both arteries. The systolic flow velocity increased by as much as 40%, and the diastolic flow velocity increased by as much as 80%. The flow velocities of the ophthalmic artery and the central retinal artery are frequently decreased in certain ocular diseases, and this decreased flow may contribute to the ocular pathology. If intravenous PGE1 is able to increase the flow velocity of these vessels in patients with peripheral vascular disease, it is possible that it is also able to increase the flow velocity of these vessels in patients with ocular disease as well. Intravenous PGE1 may prove to be a useful adjunct therapy in eyes when ischemia is part of the pathology.

Alprostadil↗
PubMed1990

[Percutaneous transluminal atherectomy in the treatment of occlusive peripheral vascular disease].

Percutaneous transluminal atherectomy (ATH) can remove the obstructing atheromatous material and may overcome the limitations of balloon angioplasty for the treatment of occlusive peripheral vascular disease. This is the first case reported in China using the Simpson rotational atherectomy device in a patient with total occlusion of left superficial femoral artery. The significant improvement in lumen was achieved by removing a tissue specimen of 14 x 4 x 3 mm3 followed by a balloon angioplasty, which reduced the residual luminal narrowing further from 50% to 20%. No acute complication was found and the patient was discharged from hospital one week after the procedure. Our results suggests that the ATH might be an effective and safe treatment for occlusive peripheral vascular disease.

Angioplasty, Balloon↗
PubMedDate not supplied

Spinal cord stimulation in the treatment of peripheral vascular disease: results of a single-center study of 258 patients.

This report is of a retrospective study of data from 258 patients who received spinal cord stimulation (SCS) for the treatment of peripheral vascular disease as a result of arteriosclerosis. The patients' clinical outcomes were monitored over a period of 18 months. In patients with a low baseline transcutaneous oxygen pressure (TcPO(2)) value of <10 mm Hg, limb survival at 18 months of follow-up (estimated by use of Kaplan-Meier survival analysis) was 77.8%, and this was even higher, at 89.5%, in patients with a medium baseline TcPO(2) value of 10-30 mm Hg. This successful treatment was accompanied by a sustained increase in TcPO(2) values to approximately 30 mm Hg in both of these groups. In looking at diabetic and nondiabetic patients, there is no difference in limb survival as a result of the treatment. It is concluded that SCS is an effective therapy in improving limb survival in patients with peripheral vascular disease. In addition, TcPO(2) values at baseline may be a useful predictor of treatment outcome.

Aged↗
PubMed1999

Noninvasive approaches to peripheral vascular disease. What's new in evaluation and treatment?

Current availability of noninvasive evaluation and treatment methods for peripheral vascular disease is unprecedented. Understanding of vascular and molecular biology, physiology, and pathology has improved significantly, as have the technologic capabilities of ultrasonography, digital imaging, therapeutic angiogenesis, and other methods not even in existence a few decades ago. However, although science continues to advance rapidly on multiple fronts and, eventually, noninvasive methods will supersede current treatment options, for the immediate future, heavy emphasis should continue to be on preventive strategies.

Genetic Therapy↗
PubMed1998

A brief history of Doppler ultrasound in the diagnosis of peripheral vascular disease.

The history of Doppler ultrasound in peripheral vascular diagnosis is considered in terms of basic developments, clinical applications and impact on medical practice. Many early developments occurred at Osaka University in Japan and the University of Washington in the United States. Through progressive steps, Doppler ultrasound technology has provided clinical applications in blood-flow sensing, waveform analysis, localizing blood flow and two-dimensional (2-D) mapping of blood flow. An important advance was the development of duplex and color Doppler scanning. Real time velocity measurements and flow mapping have led to many clinical applications. Two important applications have been detection and grading of atherosclerotic plaques in the internal carotid artery and the diagnosis of deep venous thrombosis. Doppler ultrasound is the preferred noninvasive imaging method for each of these clinical problems. The recent reaffirmation of carotid endarterectomy as the appropriate management for certain categories of carotid atherosclerotic occlusive disease has led to guidelines for selecting patients for carotid endarterectomy. New Doppler ultrasound criteria are being developed to identify categories of stenosis that relate to these guidelines. The establishment of Doppler ultrasound has led to training programs for technologists and physicians, certification of technologists and establishment of standards and quality control measures for vascular laboratories.

Blood Flow Velocity↗
PubMed2001

The Legs for Life screening for peripheral vascular disease: compliance with physician recommendations in moderate- and high-risk assessed patients.

PURPOSE: To determine compliance within a community with recommendations made by physicians during the 1999 Legs for Life National Screening for Peripheral Vascular Disease (PVD) and Leg Pain. MATERIALS AND METHODS: Patients were initially screened for PVD by completion of the Legs for Life risk factor questionnaire and determination of bilateral ankle/brachial indexes (ABIs). Each patient subsequently met with an interventional radiologist or vascular surgeon. Patients with normal ABIs (>1.0 bilaterally) or mildly abnormal ABI(s) (<1.0 but >0.90) were classified at no and low risk for PVD, respectively; patients with ABI(s) of 0.70-0.89 were classified at moderate risk for PVD; and patients with ABI(s) <0.69 were classified at high risk for PVD. Risk factors for PVD were assessed by the consulting physician and discussed with all patients. Recommendations were made for additional evaluation and/or follow-up care, if necessary. Seven months after screening, patients who were assessed at moderate and high risk for PVD were contacted by telephone to determine if they had pursued additional care or testing. RESULTS: A total of 205 patients were screened for PVD, 48 (23%) of whom were determined to be at moderate to high risk. Forty-four (92%) patients were available for follow-up. At 7 months after screening, 31 (70%) patients had received no further medical advice or treatment. Thirteen (30%) of these patients had completed a follow-up appointment, but only three with a physician specializing in peripheral vascular disease. None of the patients had clinical follow-up with an interventional radiologist. Five (11%) patients had undergone noninvasive Doppler evaluation and one (2%) had undergone diagnostic arteriography. No patient had undergone any form of percutaneous or surgical intervention. CONCLUSION: Patient compliance with physician recommendations after outpatient screening for PVD is low. The Legs for Life screening program could be considered successful in that it provides for patient education and the identification of moderate to high-risk patients. Physicians participating in this program may have to modify their approach to patient screening and follow-up if a concomitant goal is to deliver specialty care.

Adult↗
PubMedDate not supplied

Medical risk factors in diabetic patients with foot ulcers and severe peripheral vascular disease and their influence on outcome.

The association between medical risk factors and the outcome of foot ulcers was evaluated in 208 consecutive diabetic patients with severe peripheral vascular disease (systolic toe blood pressure < or = 45 mm Hg). All patients were treated and followed by the same foot care team. Eighty patients healed primarily, 83 healed after a minor or major amputation, and 45 died. The systolic toe blood pressure was higher among primary healed (30 +/- 13 mm Hg) compared with amputated (22 +/- 15 mm Hg; p < 0.001) and deceased patients (20 +/- 14 mm Hg; p < 0.001). The patients were comparable regarding age, sex, and diabetes and wound duration. Only 41 (19%) patients had intermitten claudication, whereas 153 (77%) lacked palapble pedal pulses, 36% of whom healed primarily. Rest pain occurred in 72 (33%) patients, 38 (47%) of whom had an amputation and 18 (25%) who healed primarily (p < 0.01). Peripheral edema and proteinuria were more common among patients who healed after amputation compared with those who healed primarily (p < 0.001 and p < 0.01, respectively). Signs of sensory neuropathy were found in 158 (77%) patients. There were no differences concerning cardiovascular disease, smoking habits, or short-term metabolic control between patients who healed primarily or after an amputation. In conclusion, diabetic patients with foot ulcers and severe peripheral vascular disease with low systolic toe blood pressure were not excluded from the possibility of primary healing. The most important risk factors for amputation were a systolic toe pressure of less than 30 mm Hg, peripheral edema, rest pain, and proteinuria.

Aged↗
PubMed1997

Peripheral vascular disease evaluated with reduced-dose gadolinium-enhanced MR angiography.

PURPOSE: To demonstrate the utility of low-dose gadolinium-enhanced magnetic resonance (MR) angiography of two consecutive anatomic areas for assessment of peripheral vascular disease. MATERIALS AND METHODS: Fifteen patients underwent gadolinium-enhanced MR angiography for evaluation of lower extremity peripheral vascular disease after conventional digital subtraction angiography (DSA). MR angiography was performed with three-dimensional coronal gradient-echo acquisitions before and during administration of gadopentetate dimeglumine. Two separate, contiguous areas were studied with separate doses of 0.075 and 0.1 mmol/kg gadopentetate dimeglumine. MR angiography findings were compared with DSA findings; DSA was the standard of reference. Treatment options were determined first with MR angiograms and then with DSA images. RESULTS: For distinguishing greater than 50% stenosis from 50% or less stenosis, gadolinium-enhanced MR angiography yielded a sensitivity of 97%, a specificity of 96%, and an accuracy of 97%. In 146 (97%) of 150 anatomic segments, there was essential or total agreement on treatments determined with MR angiography and DSA. In two cases (one case of vascular stent placement and one case of surgical anastomosis), extent of disease was overestimated with MR angiography. The MR study of one infrapopliteal area was insufficient for evaluation. CONCLUSION: Accurate gadolinium-enhanced MR angiography of multiple peripheral vascular areas of the lower extremities can be performed in most patients with less than 0.2 mmol/kg contrast material.

Aged↗
PubMed1997

Lipid profile and peripheral vascular disease in arseniasis-hyperendemic villages in Taiwan.

To examine whether lipid abnormalities contributed to the endemic peripheral vascular disease (PVD) in villages where arseniasis was hyperendemic in Taiwan, the authors studied 533 adults with Doppler ultrasound and lipid profiles including total cholesterol, triglyceride, high- and low-density lipoprotein cholesterol, apolipoprotein AI, and apolipoprotein B. Among them, 63 had PVD based on an ankle-brachial index < 0.90. Long-term arsenic exposure indices including cumulative arsenic exposure in mg/L-years, duration of drinking artesian well water in years, and duration of living in arseniasis-hyperendemic villages in years were calculated from detailed history obtained through standardized interviews based on a structured questionnaire and arsenic concentration in well water. Possible confounders including age, sex, body mass index, cigarette smoking, and disease status of diabetes mellitus and hypertension were considered in the analyses. None of the lipid profiles differed significantly between the presence and absence of PVD. The odds ratios for PVD did not differ among different quintiles of lipid profiles with the lowest quintile as the referent. However, a significant dose-response relation was found for the long-term arsenic exposure indices. The multivariate-adjusted odds ratios for cumulative arsenic exposure of 0.1 approximately 19.9 and > or = 20 mg/L-years were 2.77 and 4.68, respectively, compared with the unexposed. These results suggest that the PVD in arseniasis-hyperendemic villages is correlated with ingested inorganic arsenic and not with the lipid profiles.

Adult↗
PubMed1989

Smoking and peripheral vascular disease. Epidemiology and podiatric perspective.

Virtually no attention has been given in public education efforts to the potentially devastating effects of smoking on the lower extremities. An analysis of the epidemiologic studies that have been done by the Office of the Surgeon General and other clinical investigators has been presented, leading to the conclusion that cigarette smoking is the single most powerful risk factor for peripheral vascular disease. In the care of patients with peripheral vascular disease, the podiatric physician has an opportunity to be a participant in efforts to solve one of the nation's major public health problems.

Arterial Occlusive Diseases↗
PubMed2003

Effects of cilostazol on serum lipid concentrations and plasma fatty acid composition in type 2 diabetic patients with peripheral vascular disease.

Cilostazol is an anti-thrombotic and vasodilating agent, reported to have both anti-thrombotic and cerebral vasodilating effects. We investigated the effects of cilostazol on serum lipid concentrations and plasma fatty acid composition in type 2 diabetic patients with peripheral vascular disease. The serum concentrations of total cholesterol, triglycerides, high-density lipoprotein-cholesterol, lipoprotein (a), remnant-like particles-cholesterol, apolipoproteins, and plasma fatty acid composition were measured in 17 diabetic patients with peripheral vascular disease before and 1, 3, and 6 months after administration of cilostazol (200 mg/day). Serum triglyceride concentrations were significantly decreased after cilostazol (from 1.31+/-0.17 mmol/l to 0.86+/-0.07 mmol/l at 6 months, P<0.01). Plasma docosahexaenoic acid levels were significantly increased after cilostazol (4.11+/-0.26% to 4.94+/-0.26% at 6 months, P<0.01). Our findings show that cilostazol can induce some beneficial changes in serum lipid profile and plasma fatty acid composition.

Aged↗
PubMed1993

Calf vessel preservation in peripheral vascular disease--angiography versus pulse generated run-off.

Previous angiographic and radiological studies have suggested that the peroneal artery is the best preserved of the calf vessels in peripheral vascular disease and should be a site of preference for a femorodistal bypass graft. Calf vessel run-off assessed by pulse generated run-off (PGR) provides a more accurate prediction of graft success or failure than angiography and may therefore give a better functional picture of vessel patency than angiography. This study compares the presence and degree of preservation of the three calf vessels in patients with severe peripheral vascular disease using both intra-arterial digital subtraction angiography (IADSA) and PGR. Thirty-four limbs in patients with either ischaemic rest pain, ulceration or gangrene were studied and the results were scored according to the extent and severity of disease in the peroneal, posterior tibial and anterior tibial arteries. On IADSA, the peroneal artery was patent significantly more often (79%) than the posterior tibial artery (47%) or the anterior tibial artery (38%). Conversely, PGR examination showed no difference in patency between the three vessels (peroneal 91%, posterior tibial 88%, anterior tibial 79%). The peroneal artery was also significantly better preserved on IADSA (65%) compared to the posterior tibial artery (38%) and the anterior tibial artery (23%). PGR studies again showed no difference in the best preserved vessel between peroneal (47%), posterior tibial (50%) and anterior tibial (50%) arteries. Thus, the peroneal artery appears the better preserved vessel on angiography but this appearance may be misleading because the more functional PGR studies show no significant difference in the patency or degree of preservation of the three calf vessels.

Angiography, Digital Subtraction↗
PubMed1994

Gender differences in interventional management of peripheral vascular disease: evidence from a blood flow laboratory population.

Recent studies of gender differences in the treatment of coronary artery disease have concluded that female patients often receive less aggressive care than male patients. This study compares rates of lower extremity surgical and endovascular procedures by gender for peripheral vascular disease patients seen in the blood flow laboratory at our institution in 1987. Revascularization rates were compared for 192 female and 218 male patients with abnormal blood flow examinations and no prior lower extremity procedures. Female patients were older (3.3 years; p < 0.02), had a lower prevalence of ankle/brachial indices greater than 0.5 (64.2% of males vs. 51.8% of females; p < 0.01), a higher prevalence of hypertension (p < 0.03), and a lower prevalence of smoking (p < 0.02). No significant baseline differences were found for the prevalence of limb salvage indications or other comorbid conditions. A total of 41 women (21.4%) and 64 men (29.4%) underwent subsequent lower extremity surgical or endovascular procedures in 1987 (p = 0.08). Men had a significantly higher procedure rate among the 311 patients without limb salvage indications (p = 0.03). When statistically significant covariates such as limb salvage, age, ankle/brachial index, comorbidity, and smoking are controlled for in logistic regression analysis, men were found to have more than twice the chance of being selected for procedures (p = 0.009). Although limited to practice patterns at one institution, these results suggest that other centers should examine criteria for interventional therapy in mild-to-moderate peripheral vascular disease.

Aged↗
PubMed1999

Screening for asymptomatic carotid stenosis in patients with peripheral vascular disease: a prospective study and risk factor analysis.

Screening for asymptomatic carotid artery stenosis using color flow duplex scan was performed on 186 Chinese patients with peripheral vascular disease. They consist of 121 male and 65 females, with a mean age of 70.6 years. A carotid bruit was present in 43 (23.1%) of the patients. Internal carotid artery stenosis of 70% or greater was detected in 46 patients (24.7%) including six total occlusions. Another 79 patients (42.5%) had internal carotid artery stenosis in the 30-69% range. Significant internal carotid artery stenosis was associated with age, male sex, the quantity and duration of smoking and a carotid bruit, and inversely with cholesterol, triglyceride and VLDL. Age, the number of cigarettes consumed per day, and carotid bruit were independent significant predictors of > or =70% internal carotid artery stenosis on logistic regression analysis. The degree of internal carotid artery stenosis is more severe in patients with a carotid bruit, and correlated positively with age (P<0.01), the number of cigarettes smoked (P = 0.04), and the duration of smoking (P = 0.03). Multiple linear regression analysis showed that only the age of the patient bears a significant relationship with the degree of internal carotid artery stenosis (P<0.01). There was no relationship between the degree of lower limb ischemia with carotid stenosis. The prevalence of > or =70% internal carotid artery stenosis in a high risk population with peripheral vascular disease was 24.7%. Routine duplex screening is worthwhile in this group of patients, particularly in male, elderly smokers.

Aged↗