糖尿病患者外周血管病变的内科治疗证据

目的：评价糖尿病外周血管病变的几种内科治疗手段的疗效。方法：检索MEDLINE和Cochrane Database,以内科治疗糖尿病和非糖尿病的外周血管病变的Meta分析为基础,加以综述。结果：检索到13项结果,共评估了西洛他唑,己酮可可碱,抗血小板药物,运动疗法,以及控制危险因素(吸烟,高血脂和高血压等)对治疗伴或不伴糖尿病的外周血管病变的有效性。结论：西洛他唑能有效治疗糖尿病及非糖尿病患者的间歇性跛行,阿司匹林可能对糖尿病患者的血管病变有一级预防作用,己酮可可碱和运动治疗可增加间歇性跛行患者的行走能力,控制危险因素(降血糖,降血脂,降血压和戒烟)对糖尿病患者外周血管病变的影响有待进一步研究。     

Outcome of Pulmonary Vascular Disease in Pregnancy: A Systematic Overview From 1978 Through 1996

Objectives. Published reports were reviewed to evaluate the characteristics of peripartal management and the late pregnancy outcome in women with pulmonary vascular disease (PVD).

Background. Pulmonary hypertension poses one of the highest risks for maternal mortality, but actual data on the maternal and neonatal prognosis in this group are lacking.

Methods. Reports published from 1978 through 1996 of Eisenmenger’s syndrome (n = 73), primary pulmonary hypertension (PPH) (n = 27) and secondary vascular pulmonary hypertension (SVPH) (n = 25) complicating late pregnancy were included and analyzed using logistic regression analysis.

Results. Maternal mortality was 36% in Eisenmenger’s syndrome, 30% in PPH and 56% (p < 0.08 vs. other two groups) in SVPH. Except for three prepartal deaths due to Eisenmenger’s syndrome, all fatalities occurred within 35 days after delivery. Neonatal survival ranging from 87% to 89% was similar in the three groups. Previous pregnancies, timing of the diagnosis and hospital admission, operative delivery and diastolic pulmonary artery pressure were significant univariate (p < 0.05) maternal risk factors. Late diagnosis (p = 0.002, odds ratio 5.4) and late hospital admission (p = 0.01, odds ratio 1.1 per week of pregnancy) were independent predictive risk factors of maternal mortality.

Conclusions. In the last two decades maternal mortality was comparable in patients with Eisenmenger’s syndrome and PPH; however, it was relevantly higher in SVPH. Maternal prognosis depends on the early diagnosis of PVD, early hospital admission, individually tailored treatment during pregnancy and medical therapy and care focused on the postpartal period.     

A pilot goal-directed perfusion initiative is associated with less acute kidney injury after cardiac surgery

Background

We sought to determine whether a pilot goal-directed perfusion initiative could reduce the incidence of acute kidney injury after cardiac surgery.

Long-Term Outcomes of Iliofemoral Artery Stents after Transfemoral Aortic Valve Replacement

Purpose

To report long-term results of iliofemoral stent placement after transcatheter aortic valve replacement (TAVR).

Orbital atherectomy for symptomatic lower extremity disease

Background. Plaque‐debulking technologies have been proposed as alternative treatment options for peripheral arterial disease. Orbital atherectomy (OA), using the DiamondBack360® device, has emerged as one promising modality. Methods. We evaluated the safety and efficacy of OA in the first 200 lesions treated at our institution. Patient demographics, clinical characteristics, and lesion and procedural variables were collected and analyzed. The primary safety endpoint was the 30‐day major adverse events (MAE), including death, myocardial infarction, stroke, unplanned amputation, or target lesion revascularization. Other safety endpoints included access‐site complications, occurrence of dissections, perforations, distal embolization, spasm, and hemolysis. The efficacy endpoints were procedural success, need for adjunctive therapy, and improvement in ankle‐brachial index. Multivariate analysis was performed to find independent predictors of the safety endpoints. Results. One hundred seventeen (58.5%) lesions were femoral, 31 (15.5%) were popliteal, and 52 (26.0%) were tibial. The procedural success (residual stenosis ≤30%) was comparable between the femoral and tibial lesions (86.3% vs. 92.5%, P = 0.18), but significantly lower for the popliteal lesions when compared with femoral and tibial (64.7% vs. 86.3%, P = 0.058, and 64.7% vs. 92.5%, P = 0.007 respectively). MAE at 30‐days occurred in 3 (2.2%) procedures, and major access‐site complications also occurred in 3 (2.2%). There were 31 (15.5%) dissections; independent predictors were diabetes mellitus (OR: 7.3, P = 0.008), crown‐to‐RVD ratio <0.6 (OR: 11.6, P = 0.005), and atherectomy time >360 sec (OR: 11.8, P = 0.001). There were 2 (1.0%) distal embolizations, 6 (3.0%) arterial spasms, and no perforations. Laboratory evidence of hemolysis was noted in 33.8% of cases. Conclusion. Orbital atherectomy allows for a significant procedural success, limited need for stenting, and favorable safety profile. © 2010 Wiley‐Liss, Inc.     

Rupture of a peripheral popliteal artery plaque documented by intravascular ultrasound: A case report

A 58‐year‐old male with dyslipidemia and coronary spastic angina suddenly experienced pain in the right limb while walking on November 1, 2008. Right‐ankle brachial pressure index (ABI) was decreased (0.80) and left‐ABI was normal (1.24). Bilateral ABI was normal during January 2008. Ultrasonography in the right‐lower limb artery revealed severe stenosis in the right‐popliteal artery with extended and large echolucent plaques containing an isoechoic area. We carried out lower limb angiography: subtotal occlusion of the popliteal artery was found. By intravascular ultrasound (IVUS), right‐popliteal artery plaques were echolucent and eccentric; ulceration with a thin fibrous cap was noted. Percutaneous transluminal angioplasty was done and popliteal artery blood flow was improved. Right‐ABI improved to 1.13 after 4 days. To prevent the progression and rupture of the plaques, lipid‐lowering therapy and antiplatelet therapy were started. Plaque rupture of the popliteal artery was diagnosed by these characteristics on IVUS. Patients with peripheral artery disease may have plaque rupture similar to those with acute coronary syndromes who have identical unstable plaques and unstable atheromas. In addition to appropriate local revascularization, systemic therapy to stabilize the unstable plaque is indicated because failure to do so may cause recurrent events. © 2009 Wiley‐Liss, Inc.     

The vitreo-retinal interface in macular diseases

Summary  Anomalous posterior vitreous detachment occurs, when the extent of vitreous liquefaction exceeds the degree of weakening of vitreo-retinal adherence and traction is exerted at the vitreo-retinal interface. In the macular region vitreo-macular traction is obviously correlated with macular disorders like macular pucker, epiretinal membrane, macular hole formation, and vitreo-macular traction syndrome. The pathogenesis of diabetic macular edema and exudative age-related macular degeneration is more complex. However, the effectivity of vitrectomy in diabetic macular edema and high incidence of vitreoretinal adhesions in exudative age-related macular degeneration underscore the important role of the vitreous in the pathogenesis of these diseases.      

Plaque excision for the treatment of infrainguinal arterial occlusive disease

Lower extremity peripheral vascular disease has a broad spectrum of presentations, ranging from intermittent claudication, rest pain, to limb threatening tissue loss and gangrene. Over the last 10 to 15 years, short focal stenoses or occlusions have been treated using endovascular techniques, but conventional angioplasty and stenting is limited by high restenosis rates especially in longer lesions. Moreover, multilevel, complex disease is still generally considered best managed by surgical intervention. However, with the improvements in atherectomy technology, namely plaque excision and laser plaque ablation, the full spectrum of arterial occlusive lesions may now be addressed by percutaneous means with excellent limb salvage rates. Excisional atherectomy is currently exemplified by the SilverHawk Plaque Excision System, which is available in four sizes for the treatment of all infrainguinal vessels. As the apparatus is advanced, the rotational cutting blade excises a ribbon of plaque that is concurrently collected into a nosecone. Multiple passes are made, during which the blade is directed sequentially toward all quadrants of the vessel lumen. The stenotic lesion is grossly debulked by this technique with the proposed advantage of avoiding the arterial wall barotrauma that hampers the durability of angioplasty and stenting.