Anna Drelich-Zbroja

The relationship between carotid intima-media thickness and the activity of rheumatoid arthritis.

Background:Cardiovascular (CV) disease, the most common cause of mortality in patients with rheumatoid arthritis (RA), is largely attributable to accelerated atherosclerosis. Carotid intima-media thickness (cIMT) has been approved as a surrogate marker of early atherosclerosis. Objectives:The aim of the study was to assess cIMT in RA patients lacking concomitant comorbidities potentially influencing cIMT value. Methods:The study group consisted of 74 RA patients, without diagnosed heart or kidney disease, hypertension, diabetes, obesity, or current smoking (mean age, 46.4 [SD, 10.6] years; range, 19-70 years). Assessment of cIMT was determined by high-resolution B-mode ultrasonography in RA patients and 31 control subjects (mean age, 42.6 [SD, 8.0] years; range, 27-59 years). Results:The mean maximum cIMT value was significantly greater in RA patients than in control subjects (0.73 [SD, 0.14] vs 0.59 [SD, 0.12] mm; P < 0.0001). In RA patients, cIMT correlated positively with a number of immunological and inflammatory parameters and also with amino-terminal pro-brain natriuretic peptide (NT-proBNP), age, metabolic variables (serum cholesterol, creatinine, cystatin C). In multiple linear regression analysis, significant association was found between cIMT and NT-proBNP and age. Patients without atherosclerosis (cIMT <0.6 mm) were younger and had significantly lower concentrations of NT-proBNP and total cholesterol, as well as higher estimated glomerular filtration rate. The course of RA in patients without atherosclerosis was characterized by shorter disease duration, lower tender joint count, and C-reactive protein. Conclusions:Values of cIMT were significantly greater in RA compared with control subjects. Features of RA, such as extra-articular manifestations, erosions, high inflammatory parameters, and long disease duration, even in the absence of traditional clinical CV risk factors, were associated with greater cIMT, suggesting an unfavorable CV risk profile.

Endovascular transcatheter embolization of recurrent postsurgical varicocele: anatomic reasons for surgical failure.

Background Formation or pre-existence of collateral gonadal veins in varicocele patients has been reported as the main cause of surgical treatment failure. Purpose To describe venographic findings in patients with postsurgical recurrent varicoceles and to assess the efficacy of the following minimally invasive endovascular treatment. Material and Methods Thirty-three men with failed surgical treatment of left-sided varicocele were examined between 2006 and 2013, using retrograde venography to assess the anatomy of varicocele draining veins before the attempted transcatheter embolization. Anatomic variants of gonadal veins were categorized according to the classification modified for the purpose of the present study. 3% polidocanol was used as an embolic agent together with pushable fibered coils. Results In 31 (93%) out of 33 patients venography demonstrated incompetence of the gonadal vein or veins draining varicoceles after failed surgical treatment. The most frequent venographic finding was gonadal vein duplication – 66% of cases (39% in its mid-portion). Technical success of embolization was achieved in all 31 patients. No major complications were observed. Conclusion Retrograde varicocele embolization may be superior to surgery because of its ability to detect gonadal vein variants. In our study group, transcatheter embolization with 3% polidocanol and fibered coils allowed successful, minimally invasive treatment of postsurgical varicoceles.

Aortic Stiffness, Left Ventricle Hypertrophy, and Homogeneity of Ventricle Repolarization in Adult Dialyzed Patients

Aim. Study was designed to assess relationship between aortic compliance and homogeneity of heart electrical activity in dialysis patients. Methods. Study group was consisted of 120 dialyzed patients; 57 (age 50,7 ± 7,1) were on continuous ambulatory peritoneal dialysis (CAPD) and 73 (age 51,6 ± 7,6) were hemodialyzed (HD). Three-dimensional vectorocardiographic (VCG) monitoring was done to assess: QRS-T angle, T el and T az. Echocardiography was performed to assess: Aomax, Aomin, ASI (aortic siffness index). Results. ASI in HD as well as in CAPD patients was significantly higher compared to controls [resp., 5,51 (±1,32), 5,83 (±1,41), 3,07 (±1,09)]. Cut-off value of ASI was 5,67. In HD patients strong correlations between ASI and QRS-T angle, T el and T az were determined (resp., r = 0,429, P < 0,001; r = 0,432, P ≤ 0,001 and r = 0,387, P = 0,001). In CAPD group were significant association between ASI and QRS-T angle, T el and T az (resp., r = 0,452, P < 0,001; r = 0,417, P < 0,001 and r = 0,390, P = 0,001). ASI was independently and markedly associated with: QRS-T angle, T elev, T az, ADMA, cTnT, CRP, Total-chol, LDL-chol in HD and CAPD patients. Conclusions. ASI and VCG indices are higher in HD and CAPD patients. Correlation between ASI and VCG parameters may reflect unfavourable influence of poor aortic compliance on the electrical activity of the heart in dialyzed patients. Hypertrophy aggravates repolarization disturbances in hemodialyzed patients.

The diagnostic value of levovist in Doppler imaging of visceral arteries in patients with abdominal angina before and after angioplasty.

PURPOSE To assess the diagnostic value of Levovist in the ultrasound imaging of visceral arteries in patients with clinical symptoms of abdominal angina, before and after percutaneous transluminal angioplasty (PTA). MATERIAL AND METHOD During a 12-month period (2000/2001) five patients with visceral arterial stenoses had ultrasound examinations and a subsequent PTA procedure. Indications for ultrasound examination were abdominal angina symptoms persisting for 3-5 years, (postprandial abdominal pain, diarrhea, and vomiting). In all patients ultrasound examinations were performed using color and spectral Doppler before and after Levovist injections. Color Doppler images and maximum blood flow velocity in stenosed visceral arteries were assessed. Patients underwent control Doppler examinations with Levovist injections to assess the effect of PTA. RESULTS In three patients conventional Doppler examination did not allow proper evaluation of visceral arteries, because of weak color and spectral Doppler signal and in two remaining patients visceral arteries were not visualized at all. In all five patients strong enhancement of color and spectral Doppler signal was observed after Levovist administration. In all these cases a hemodynamically significant stenosis was diagnosed: coeliac trunk-2 and superior mesenteric artery-3. PTA was performed successfully in these patients. In one of them ultrasound examination done before Levovist injection allowed good visualization of treated SMA and showed good PTA result. In the remaining four patients Doppler examination with the use of Levovist demonstrated visceral arteries well and confirmed successful PTA procedures. CONCLUSIONS The use of Levovist makes the diagnostic efficiency of Doppler examinations much higher. In most cases it allows an unequivocal diagnosis of visceral artery stenosis in patients with abdominal angina symptoms. The Doppler examination with the use of Levovist is the method of choice in follow-up after PTA.

Left atrial volume index as a predictor of ventricle repolarization abnormalities in adult dialyzed patients

This study was performed to investigate the relationship between left atrium (LA) volume index (LAVI) and left ventricle electrical activity presumably repolarization in end‐stage renal disease patients. Study group was consisted of 120 dialyzed patients divided into two subgroups: 57 (age 50.7 ± 7.1) were on continuous ambulatory peritoneal dialysis (CAPD) and 73 (age 51.6 ± 7.6) were hemodialyzed (HD). All patients were undergoing three‐dimensional vectorcardiographic (VCG) monitoring to assess parameters concerning T vector: QRS‐T angle, Tel, and Taz. Standard echocardiography was performed to assess: LAmax, LAshort, LAlong. LAVI was calculated due to formula: LAVI = (π/6X [LAmax × LAshort × LAlong])/m2. LAVI in HD as well as in CAPD patients was significantly higher compared with controls (respectively: 36.29 ± 10.92; 36.41 ± 11.06; 20.64 ± 6.77 mL/m2). The calculated cutoff value of LAVI was 36.32 mL/m2. In HD patients, the strong correlations between LAVI and QRS‐T angle and Tel were determined (respectively: r = 0.407, P < 0.001 and r = 0.359, P = 0.006). Similarly in CAPD group were significant associations between LAVI and QRS‐T angle and Tel (respectively: r = 0.423, P < 0.001 and r = 0.374, P = 0.004). The QRS‐T angle, Tel and Taz are independently and markedly associated with LAVI in both HD and CAPD patients. LAVI and VCG indices are higher in both HD and CAPD patients. Correlation between QRS‐T angle and LAVI may reflect unfavorable influence on the electrical activity of the heart in dialyzed patients with left ventricle diastolic dysfunction. LAVI cutoff value is useful biomarker for stratification of ventricle repolarization disturbances in those patients.

Uterine artery embolisation for the treatment of symptomatic uterine fibroids

Introduction. Uterine fibroids are the most common benign uterine tumours which can be treated with conservative, surgery or minimally invasive methods. Selection of patients for embolisation seems to be essential. Aim. Assessment of efficacy and safety of uterine artery embolisation with hydrogel microparticles coated with an anti-inflammatory agent for reduction in symptomatic uterine fibroid volumes. Material and methods. In the prospective observational study carried out between January 2011 and December 2013, 206 patients with symptomatic fibroids were qualified for uterine artery embolisation. 118 aged 32 to 51 (average 39), who reported for follow-ups 3-4 months after procedures, were evaluated. According to the number of fibroids, patients with 2/4 fibroids predominated (78 patients), followed by those with single fibroids (25) and with myomatous uteri (14 patients). According to fibroid sizes, 4 groups were distinguished: < 7 cm in 77 patients, 7-12 cm in 19, > 12 cm in 8, and myomatous uteri in 14 patients Results. A mean decrease in fibroid volume in the entire study population was 62%, ranging from 9% in the patient with a hyalinised fibroid to 100% in patients with separated submucosal fibroids. Conclusions. UAE is a safe and effective treatment for symptomatic uterine fibroids. In addition to reducing the symptoms, significantly reduces their volume. The key to success is proper qualification, as well as cooperation between the radiologist and the gynecologist.

Management of carotid stenosis. History and today.

Internal carotid stenosis constitutes a significant clinical challenge, since it is the cause of 20–25% of ischemic brain strokes. The management of the internal carotid stenosis for many years has been raising controversies amongst neurologists, vascular surgeons and interventional radiologists mainly due to the introduction of endovascular stenting as an alternative to surgical treatment. Its application, however, requires knowledge of specific selection criteria for this kind of treatment as well as of the methods of monitoring patients after stent implantation into the internal carotid artery. Duplex Doppler ultrasound examination is currently a basis for the diagnosis of the arterial stenosis of precranial segments of the carotid arteries. It allows a reliable assessment of not only the course and morphology of the walls, but also of the hemodynamics of blood flow. Interventional treatment is applicable in patients with internal carotid stenosis of ≥70%, which is accompanied by an increase of the systolic flow velocity above 200 cm/s and the end-diastolic velocity above 50–60 cm/s in the stenotic lumen. In most cases, such a diagnosis in duplex Doppler ultrasound examination does not require any confirmation by additional diagnostic methods and if neurological symptoms are also present, it constitutes a single indication for interventional treatment. When deciding about choice of surgical or endovascular method of treatment, the following factors are of crucial importance: morphology of atherosclerotic plaque, its size, echogenicity, homogeneity of its structure, its surface and outlines. By means of ultrasound examinations, patients can be monitored after endovascular stent implantation. They enable evaluation of the degree of stent patency and allow for an early detection of symptoms indicating stenosis recurrence or presence of in-stent thrombosis. When interpreting the findings of the US checkup, it is essential to refer to the initial examination performed in the first days after the procedure and the next ones conducted during the monitoring period.

Leigh syndrome in individuals bearing m.9185T>C MTATP6 variant. Is hyperventilation a factor which starts its development?

Leigh syndrome (LS), subacute necrotizing encephalomyelopathy is caused by various genetic defects, including m.9185T>C MTATP6 variant. Mechanism of LS development remains unknown. We report on the acid-base status of three patients with m.9185T>C related LS. At the onset, it showed respiratory alkalosis, reflecting excessive respiration effort (hyperventilation with low pCO2). In patient 1, the deterioration occurred in temporal relation to passive oxygen therapy. To the contrary, on the recovery, she demonstrated a relatively low respiratory drive, suggesting that a “hypoventilation” might be beneficial for m.9185T>C carriers. As long as circumstances of the development of LS have not been fully explained, we recommend to counteract hyperventilation and carefully dose oxygen in patients with m.9185T>C related LS.

Double thrombolysis in early pregnancy can be safe

We describe the case of pregnant patient with diagnosed massive pulmonary embolism, who underwent successful double thrombolysis. A 23-year-old woman in the 7th week of her 3rd pregnancy was admitted to the Intensive Cardiac Care Unit 2 h after sudden onset of chest pain and dyspnoea. An immediate electrocardiography showed sinus tachycardia with typical S1Q3T3 pattern and rsr’ complex in lead V1. Transthoracic echocardiography on admission revealed right ventricular strain. We performed emergent computed tomography angiography of the chest, which showed significant thrombus in both pulmonary arteries, resulting in restricted blood flow. The patient was treated with unfractionated heparin infusion, monitored by activated partial thromboplastin time. Because of her deteriorating condition, we administered alteplase (10 mg bolus, then 90 mg over the next 2 h). Ultrasonography examination of her pelvis and lower extremities revealed spindle-shaped thrombus of the right common iliac and external iliac veins. On her 10th day of hospitalisation, during the patient’s mobilisation, she presented with symptoms of shock. She needed endotracheal intubation, mechanical ventilation and vasoconstrictor support. We treated her with a second round of full dose alteplase. No complications further developed for the mother or foetus in the subsequent days. She gave birth to a healthy son weighing 3580 g with Apgar score of 10 points in her 38th week of pregnancy by natural delivery. After delivery we switched low molecular weight heparin to warfarin according to her international normalised ratio. In conclusion, double thrombolysis in early pregnancy proved to be safe for both the mother and child, but additional studies need to be performed.

Endovascular treatment for superior vena cava obstruction

Summary Introduction. Superior vena cava syndrome (SVCS) is common complication of malig- nancy, the lung cancer is the most common cause. The clinical indication for superior vena cava (SVC) endovascular treatment is allevation of superior vena cava syndrome (SVCS) caused by malignant obstruction. Aim. Evaluation of safety and efficacy of SVC stenting in patients with malignant supe- rior vena cava syndrome (SVCS) n our experience. Material and methods. Between 2011 and 2014, data of 112 patients with SVC syn- drome, mostly of malignant aetiology, were retrospectively collected. The study included 68 men and 44 women (mean age n 64; range 43-79 years). Results. Stent placement was technically successful in 98% cases. Two stents were found to be obstructed after several months and patients needed repeated angioplasty. There was no stent migration to the right atrium. Haemoptysis was observed in one patient and pulmonary embolism in two cases. There were no major remote complications. Conclusions. Endovascular stenting has become a safe and cost effective treatment for patients with SVCS, providing rapid relief of symptoms and improving their quality of life. Endovascular stenting should be performed in each patient with SVCS.