Medical treatment of peripheral arterial disease: a comprehensive review

Peripheral arterial disease (PAD) is a common manifestation of atherosclerosis that affects more than 10 million people in the United States. The risk factors associated with PAD are similar to those found in patients with coronary artery disease and cerebrovascular disease. Medical therapy of PAD must include modification of cardiovascular risk factors with application of strict secondary prevention guidelines. For improvement in quality of life, a structured exercise rehabilitation program remains the most effective noninterventional treatment strategy, but it is difficult to employ from economic and patient-compliance perspectives. Newer pharmacologic therapies have demonstrated efficacy in patients with intermittent claudication. Emerging strategies for management of these patients include revascularization and maximal medical therapy for improvement of physical function as well as reduction in risk for subsequent major cardiovascular events. This article will review the clinical data supporting aggressive medical interventions for patients with PAD.     

Muscle fiber characteristics in patients with peripheral arterial disease.

PURPOSE: There have been conflicting reports of muscle fiber type changes in patients with peripheral arterial disease (PAD). The purpose of this study was to examine the myosin heavy chain (MHC) expression as well as histochemical changes in the gastrocnemius muscle in patients with symptomatic PAD. METHODS: Needle biopsy specimens were obtained from the medial gastrocnemius of 14 subjects with PAD (mean age (+/- SD), 69.7 +/- 4.8 yr) and eight activity-matched control subjects (mean age, 65.1 +/- 6.6 yr). Ankle-brachial index was assessed using Doppler ultrasound to determine the hemodynamic status of the patients, and maximal walking performance was determined during a graded treadmill test. Expression of MHC isoforms was determined by SDS-PAGE. RESULTS: The proportion of MHC I was significantly smaller in PAD than in the controls (45.6 +/- 9.1% vs 58.8 +/- 15.0%). The proportion of MHC IIx was also larger in the subjects with PAD compared with the controls (22.9 +/- 9.1% vs 16.0 +/- 11.3%). In addition, there was a significant decrease in the cross-sectional area of the type I and type IIA fibers in the subjects with PAD as well as enhanced capillary density. CONCLUSIONS: This study showed a significant modification in the expression of MHC isoforms and muscle fiber type in the gastrocnemius in patients with symptomatic PAD. These results suggest that muscle ischemia resulting from PAD is an important factor in causing the adaptations in the contractile apparatus of the muscle.     

Exercise for patients with chronic disease: physician responsibility

Patients with chronic disease typically become severely deconditioned, which often leads to physical disability. Every effort should be made to recommend and encourage patients to adopt and maintain a program of physical activity. Although there are no specific exercise guidelines for many chronic conditions, patients should be instructed to start a routine of physical activity that is gradual for most (if not all) days of the week, working up to 30 minutes per session at an exertion level that is easily tolerated. It is critical that assessment of physical functioning and recommendations for physical activity be included as a part of routine medical care. In doing so, we change the expectations of patients and family members, and work toward optimizing physical functioning and quality of life.     

Hodgkin's disease of the oesophagus: a literature review

Hodgkin's disease rarely involves the gastrointestinal tract. Primary Hodgkin disease of the oesophagus seems to be extremely rare. We report a case of classical Hodgkin's disease involving lower end of oesophagus.     

Fibrinolytic response to acute exercise in patients with peripheral arterial disease

PURPOSE: Elevations in tissue plasminogen activator (tPA) are postulated to protect against atherothrombotic events during exercise. However, fibrinolytic response to repetitive bouts of symptom-limited exercise is unknown in peripheral arterial disease (PAD) patients, a population with impaired fibrinolysis and increased risk for ischemic events. The purpose of the present study was to evaluate the fibrinolytic response to repetitive bouts of symptom-limited exercise in PAD patients. METHODS: Nine (8 male, 1 female) patients with Fontaine State II PAD were studied. Fasting blood samples for determination of tPA and plasminogen activator inhibitor (PAI-1) were obtained into an acidified citrate solution via an indwelling venous catheter before, immediately after, 30 min after, and 60 min after submaximal treadmill walking. Patients walked intermittently at 65% of maximal intensity achieved on a previous graded exercise test until 30 min of exercise was achieved. RESULTS: Exercise increased tPA activity by 180% (0.5 +/- 0.16 IU.mL(-1) baseline, 1.4 +/- 1.2 IU.mL(-1) postexercise), and decreased PAI-1 activity by 40% (20.6 +/- 5.5 AU.mL(-1) baseline, 11.8 +/- 6.2 AU.mL(-1) postexercise), without changing tPA or PAI-1 antigen. Notably, plasma tPA activity levels 1 h after exercise remained elevated by 80%, whereas PAI-1 activity remained decreased by 49%. The decrease in PAI-1 significantly (P < 0.05) correlated with oxygen uptake (VO(2)) during submaximal exercise (r = -0.77). CONCLUSION: These findings demonstrate that repetitive bouts of symptom-limited exercise produce a substantial improvement in the fibrinolytic profile of PAD patients, which persists at least 1 h after exercise cessation.     

Exercise and primary dysmenorrhoea : a comprehensive and critical review of the literature

Primary dysmenorrhoea (PD) is chronic, cyclic, pelvic, spasmodic pain associated with menstruation in the absence of identifiable pathology and is typically known as menstrual cramps or period pain. PD is the most common gynaecological disorder in menstruating women. Despite treatments being available for PD, relatively few women consult a clinician about their symptoms, preferring not to use treatment, or to self-treat using non-pharmacological or over-the-counter interventions. The notion that exercise is effective in preventing and treating symptoms has prevailed for many years and led to the promotion of anecdotal belief that exercise is beneficial. Behavioural interventions such as exercise may not only reduce dysmenorrhoea, but also eliminate or reduce the need for medication to control menstrual cramps and other associated symptoms.With emphasis on data from experimental studies, this report seeks to review the available evidence regarding the role of exercise in the management of PD and menstruation-related symptomatology. Using key search terms, online bibliographical databases were searched from the beginning of each database to 1 April 2007. Despite the widespread belief that exercise can reduce PD, empirical support is limited. Evidence from observational studies was mixed. Several observational studies reported that physical activity/exercise was associated with reduced prevalence of dysmenorrhoea, although numerous other studies found no significant association between outcomes. Evidence from controlled trials suggests that exercise can reduce PD and associated symptoms, but these have been small and of low methodological quality. There are, however, several plausible mechanisms by which exercise might be effective in the management of PD. A large randomized controlled trial is required before women and clinicians are advised that exercise is likely to be effective in reducing PD and related menstrual symptoms.     

Whole-body 3D MR angiography of patients with peripheral arterial occlusive disease

OBJECTIVE: We assessed the diagnostic performance of whole-body 3D contrast-enhanced MR angiography in comparison with digital subtraction angiography (DSA) of the lower extremities in patients with peripheral arterial occlusive disease. SUBJECTS AND METHODS. Fifty-one patients with clinically documented peripheral arterial occlusive disease referred for DSA of the lower extremity arterial system underwent whole-body MR angiography on a 1.5-T MR scanner. Paramagnetic gadobutrol was administered and five contiguous stations were acquired with 3D T1-weighted gradient-echo sequences in a total scanning time of 72 sec. DSA was available as a reference standard for the peripheral vasculature in all patients. Separate blinded data analyses were performed by two radiologists. Additional vascular disease detected by whole-body MR angiography was subsequently assessed on sonography, dedicated MR angiography, or both. RESULTS: All whole-body MR angiography examinations were feasible and well tolerated. AngioSURF-based whole-body MR angiography had overall sensitivities of 92.3% and 93.1% (both 95% confidence intervals [CIs], 78-100%) with specificities of 89.2% and 87.6% (both CIs, 84-98%) and excellent interobserver agreement (kappa = 0.82) for the detection of high-grade stenoses. Additional vascular disease was detected in 12 patients (23%). CONCLUSION: Whole-body MR angiography permits a rapid, noninvasive, and accurate evaluation of the lower peripheral arterial system in patients with peripheral arterial occlusive disease, and it may allow identification of additional relevant vascular disease that was previously undetected.     

Intraarterial MR angiography and DSA in patients with peripheral arterial occlusive disease: prospective comparison

PURPOSE: To prospectively evaluate the accuracy of intraarterial magnetic resonance (MR) angiography in the depiction of significant stenoses and occlusions, with intraarterial digital subtraction angiography (DSA) serving as the reference standard. MATERIALS AND METHODS: Approval of the local ethics committee and informed consent were obtained. Twenty patients (11 men; nine women; age range, 48-86 years; mean age, 69.5 years+/-11.2 [standard deviation]) with symptomatic peripheral arterial occlusive disease (PAOD) were prospectively enrolled. After percutaneous transluminal angioplasty (PTA), intraarterial MR angiography was performed in the thigh and the calf with a 1.5-T MR imager in two consecutive runs. Intraarterial MR angiography was performed with a low-dose injection protocol (ie, two 20-mL injections of a 50-mmol gadolinium-based contrast agent). Moderate stenoses (luminal narrowing50%) or vessel occlusions; 95% confidence intervals (CIs) were calculated for sensitivity and specificity. RESULTS: Intraarterial DSA revealed 78 moderate stenoses, 57 significant stenoses, and 28 occlusions. Sensitivity, specificity, and accuracy of intraarterial MR angiography in the characterization of significant stenoses or occlusions were 92% (95% CI: 72%, 99%), 94% (95% CI: 82%, 98%), and 93%, respectively, in femoropopliteal arteries and 93% (95% CI: 83%, 98%), 71% (95% CI: 51%, 86%), and 86%, respectively, in infrapopliteal arteries. The main artifact observed with intraarterial MR angiography was venous contamination (12%). CONCLUSION: Intraarterial MR angiography is an accurate method used to depict significant stenoses and occlusions in lower extremity arteries with a low-dose injection protocol.     

比较外周动脉疾病病人的标准与低管电压MDCT血管成像

目的评价在外周动脉疾病病人中应用对比剂减量的低管电压CT血管成像定性、定量参数的效果以及辐射剂量。方法 80例病人分为2组:一组使用的参数为120kV,对     

非增强MRA诊断下肢动脉病变的应用研究

目的：探讨QISS非增强MRA技术诊断下肢动脉闭塞性病变的临床应用价值。方法：51例下肢动脉病变患者行双下肢QISS-MRA和CE-MRA扫描,评价两种检查方法的图像质量,并以CE—MRA为参照标准,计算QISSMRA诊断下肢动脉显著性狭窄（≥50％）的敏感度、特异度、阳性预测值、阴性预测值和诊断准确性,并以配对χ2检验分析两种检查方法对诊断下肢动脉显著性狭窄（≥50％）的差异有无统计学意义,两种检查方法的相关性采用kappa检验。结果：51例中48例成功行QISS-MRA检查,其中图像质量优、良、差者分别为40（78．43％）、8（15．69％）和3例（5．88％）。按血管节段计算,QISS-MRA诊断下肢动脉显著性狭窄的敏感度和特异度分别为90．15％和98．87％,阳性预测值和阴性预测值分别为96．75％和96．42％,总体符合率为95．91％。对于下肢动脉显著性狭窄的诊断,QISS-MRA与CE-MRA的差异无统计学意义（χ2=3．76,P〉0．05）,且两种检查方法具有极好的相关性（r值为0．950,P〈0．001）。结论：QISS-MRA检查成功率较高、图像质量良好并且诊断效果接近CE—MRA,对诊断下肢动脉闭塞性病变有一定的临床应用潜力。     

Drug-eluting stents: potential applications for peripheral arterial occlusive disease

Many different approaches have been evaluated to prevent restenosis in stents after vascular implantation. Currently, drug-eluting stents are extremely promising in suppressing neointimal hyperplasia. Various animal studies and randomized trials in humans have shown excellent results in terms of safety and efficacy during intermediate-term follow-up. This article will give an overview of experimental and clinical data of the different agents in published and ongoing trials.     

MRI of patients with cardiac pacemakers: a review of the medical literature

OBJECTIVE: Numerous studies testing the use of pacemakers with MRI have been published. Our aim was to analyze these trials to determine the safety of MRI for patients with cardiac pacemakers. We performed a systematic search of peer-reviewed databases. A total of 31 articles were reviewed. CONCLUSION: The data are heterogeneous with regard to MRI being considered for patients with pacemakers, and the benefits of the imaging should outweigh the risks.     

Percutaneous intravascular US as adjunct to catheter-based interventions: preliminary experience in patients with peripheral vascular disease

Catheter-based ultrasound (US) transducers may be introduced into the vascular system to record high-resolution images of the vessel wall and lumen. The potential advantages and existing liabilities of percutaneous intravascular US as an adjunct to transluminal vascular recanalization were investigated. A 6.6-F braided, polyethylene catheter enclosing a rotary drive shaft with a single-element, 20-MHz transducer at the distal tip was used in 17 patients undergoing percutaneous transluminal (balloon) angioplasty (PTA) alone (10 patients), PTA with implantation of an endovascular stent (two patients), atherectomy alone (two patients), or laser angioplasty with PTA and/or atherectomy (three patients). The arteries treated and examined included the common iliac in five patients, the external iliac in two, the superficial femoral in nine, and a vein graft-arterial anastomosis in one. In 14 cases PTA was employed as sole or adjunctive therapy; plaque cracks were clearly delineated with intravascular US in all 14 (100%) and dissections were observed in 11 (78%). Plaque-arterial wall disruption was less prominent in the arteries treated with mechanical atherectomy. The results of laser angioplasty reflected the adjunctive modality employed. After stent implantation, serial intravascular US documented effacement of PTA-induced plaque cracks and/or dissections. Intravascular US also aided in the quantitative assessment of luminal cross-sectional areas after the procedures (19.0-51.8 mm2). The observations recorded in this preliminary group of 17 patients illustrate the potential utility of intravascular US as an adjunct to conventional angiography in patients undergoing percutaneous revascularization.     

Assessment of peripheral arterial vascular disease with radionuclide techniques

Various radioisotopic imaging techniques for noninvasive detection of vessel stenosis and for functional investigation of reduced blood flow and follow-up have been developed during the last decade in peripheral vascular disease (PVD), with the aim of replacing invasive techniques and complementing standardized methods. Radionuclide assessment of PVD is divided into 2 major groups: imaging of perfusion and metabolic investigations. The measurement of arterial blood flow and muscle perfusion is intended to show the morphology, to evaluate the functional consequences of PVD, and to quantify the latter. The application of radiolabeled tracers was developed as a noninvasive alternative to angiography in morphologic imaging. Treadmill testing has been used to assess the functional effects of reduced blood flow in PVD where the onset of pain indicates the stage of disease, but the results can be confused by other symptoms. Scintigraphic measurement of muscle perfusion should detect insufficient nutritional blood flow in peripheral muscle and thus have a higher specificity for PVD than treadmill testing alone. Although there are very promising theoretical and experimental data in animals, the clinical use of radionuclide investigations is limited by different technical problems, such as methodologic differentiation between skin and muscle perfusion, the lack of controlled and prospective studies, and incomplete correlation with other standardized routine techniques. Among the great number of radioisotopic metabolic imaging techniques, only radiolabeled platelets and lipoproteins, to some extent, have shown a limited potential clinical use. Some other approaches seem to have a high potential from a theoretical point of view. They are limited, however, by a great number of problems. Correlation with sonographic or magnetic resonance imaging (MRI) findings may identify a potential metabolic value. Correlation with angiography reflecting the extent of the disease makes no sense. So far with PVD, neither radioisotopic perfusion studies nor metabolic imaging techniques are able to achieve a level of routine application or wider meaningful interpretation of the clinical condition of a specific patient. Competing techniques are easier to perform, less expensive, faster, more widely available, and do not carry the radiation burden. Positron emission tomography is still in its early stages of application, with great theoretical potential but at a high price. A great deal of work is still required to transform in vitro and experimental experience into more meaningful routine radioisotopic investigations in patients with PVD.     

Comparison of standard- and low-tube voltage MDCT angiography in patients with peripheral arterial disease

Objective:  

We investigated the effect of low-tube-voltage CT angiography with a reduced volume of contrast agent on qualitative and quantitative parameters and the radiation dose in patients with peripheral arterial disease.     

Exoseal for puncture site closure after antegrade procedures in peripheral arterial disease patients

PURPOSE

Exoseal is a vascular clo sure device consisting of a plug applier and a bio-absorbent polyglycolic acid plug available in sizes 5 F, 6 F, and 7 F. In this study, we aimed to evaluate the effectiveness and safety of the Exoseal vascular closure device (Cordis Corporation, Bridgewater, New Jersey, USA) for puncture site closure after antegrade endovascular procedures in peripheral arterial occlusive disease (PAOD) patients.

MATERIALS AND METHODS

In this retrospective study, a total of 168 consecutive patients who underwent an interventional procedure due to PAOD, were included. In each case, an antegrade peripheral endovascular procedure was performed via the common femoral artery using the Seldinger technique, and Exoseal 5 F, 6 F, or 7 F was used for access site closure. The primary endpoint was a technically successful application of Exoseal. All complications at the access site within 24 hours were registered as a secondary endpoint.

RESULTS

In a group of 168 patients (64.9% men, average age 71.9±11.9 years), the technical application of Exoseal was successful in 166 patients (98.8%). Within the first 24 hours after the procedure, 12 complications (7.2%) were recorded including, three pseudoaneurysms (1.8%) and nine hematomas (5.4%). None of the complications required surgical intervention.

CONCLUSION

Exoseal is a safe and effective device with high technical success and acceptable complication rates for access site closure after antegrade peripheral endovascular procedures.Femoral access sites are important sources of complications in endovascular procedures. In addition to conventional manual compression, arterial closure devices have been successfully used for the purpose of hemostasis at the femoral arterial access site in interventional radiology, cardiology, and angiology for several years. The effectiveness and safety of these devices have already been proven in numerous studies (1). Vascular closure devices were developed to address the increasing time constraints in everyday clinical routine, as well as to increase patient comfort after interventional procedures. Most of these devices have been evaluated for retrograde access.Exoseal (Cordis Corporation, Bridgewater, New Jersey, USA) is a vascular closure device consisting of a plug applier and a bio-absorbent polyglycolic acid plug available in sizes 5 F, 6 F, and 7 F. Exoseal is inserted into the branch canal directly outside the arterial vessel wall and underneath the fascia of the neurovascular bundle. The polyglycolic acid plug increases platelet aggregation, as well as promoting erythrocyte accumulation within the network of the plug. This results in closure of both vessel wall and branch canal. Exoseal gets hydrolyzed into carbon dioxide and water via the Kreb’s cycle and it is completely reabsorbed within 60–90 days (2).The available data studying the role of Exoseal in peripheral vascular interventions is limited, and to this date, there are only two studies published that address the use of this device in antegrade femoral access (3, 4).The aim of this study was to evaluate the effectiveness and safety of Exoseal use for access site closure following antegrade vascular procedures on peripheral arterial occlusive disease (PAOD) patients. According to our literature research, this is the largest patient cohort that has been investigated in that respect so far.     

CT angiography of peripheral arterial disease

Lower-extremity computed tomographic (CT) angiography (ie, peripheral CT angiography) is increasingly used to evaluate patients with peripheral arterial disease. It is therefore increasingly important for all vascular specialists to become familiar with the strengths and limitations of this new technique. The aims of this review are to explain the principles of scanning and injection technique for a wide range of CT scanners, to explain and illustrate the properties of current image postprocessing tools for effective visualization and treatment planning, and to provide an overview of current clinical applications of peripheral CT angiography.     

Management of dyslipidemia with statins in the patient with peripheral arterial disease

The relationship between peripheral arterial disease (PAD), cardiovascular disease (CAD), and underlying atherosclerotic risk factors such as dyslipidemia, smoking, diabetes, and hypertension is well established. Patients with PAD have dramatically increased risks of cardiovascular mortality due to underlying atherosclerosis. As interventionalists, we focus primarily on improving the functional status of our patients by "fixing" their peripheral arterial occlusions, often ignoring the more serious concerns, as well as the root cause of the problem. In addition to interventional strategies, comprehensive clinical management of PAD should include attention to risk factor modification, lifestyle changes, exercise therapy, and pharmacologic interventions. Conventional training in interventional radiology imparts very little familiarity with these management issues. The following article addresses one critical modifiable risk factor, dyslipidemia, and treatment with the powerful class of drugs, the statins, reviewing the rationale for as well as the practical considerations in the use of these agents.