Chanean Ruangsetakit

Optimization of the table speed of lower extremity CT angiography protocols in different patient age groups

BACKGROUND Scanning with 64-slice multidetector row CT (MDCT) is usually faster than blood flow in peripheral arteries of the lower extremities, and the distal arteries of lower extremities are difficult to visualize, particularly in elderly patients. Thus, the optimal table speed for CT angiography (CTA) studies should be adjusted for appropriate patient age groups. OBJECTIVE We evaluated the relative efficacy of different table speeds in several age groups of patients with suspected peripheral arterial occlusive disease (PAOD) undergoing CTA of lower extremity arteries, as a guideline for routine use. METHODS This retrospective study reviewed routine CTA of the lower extremity arteries of 107 patients with suspected PAOD to evaluate vascular opacification in each vascular segment of 5 age groups: < or =40 years (group 1), 41-60 years (group 2), 61-70 years (group 3), 71-75 years (group 4), and > or =76 years (group 5). Adequate vascular opacification was measured for attenuation in the suprarenal and infrarenal abdominal aorta and in the arteries of the lower extremity. Venous contamination was also measured. RESULTS Adequate vascular opacification from the suprarenal aorta to the level of the mid-popliteal artery was shown in all patients. Arterial opacification at the dorsalis pedis or plantar arteries was visualized in 85.7%-91.7% of patients and at the plantar arch arteries in 84.1%-91.7%. Minimal venous contamination was also shown adjacent to arterial enhancement, ranging from 0% to 28.6%. CONCLUSION Performing CTA of the lower extremities with 64-slice MDCT could reduce the table speed to allow adequate arterial opacification and minimal venous contamination.

Pedal bypass with deep venous arterialization: the therapeutic option in critical limb ischemia and unreconstructable distal arteries.

Heavily calcified and severely stenotic distal arteries defined as unreconstructable, precludes the possibility of revascularization, resulting in major amputation in patients with critical limb ischemia. However, providing blood supply to the ischemic foot through the venous system instead of the arterial system may improve the circulation adequately for the healing process in the vascular compromised distal tissue. This study aimed to assess the safety and efficacy of pedal bypass with deep venous arterialization, one of the possible procedures to improve the circulation through the venous system in critically ischemic limbs and unreconstructable distal arteries. Twenty-six patients with critical limb ischemia and an unreconstructable distal artery of the lower extremities were included for the surgical procedure. Arterial bypass with distal anastomosis at the paramalleolar deep vein was carried out through a composite graft combined with adequate destruction of valve competency in the distal vein. The primary endpoint was complete healing of ischemic ulcer with amelioration of rest pain within six months. The secondary endpoints were the outcomes of survival, limb salvage and primary graft patency rate at six-month intervals to 24 months. Nineteen patients (73.1%) had complete healing of ischemic ulcer and disappearance of rest pain within six months. Six patients (23.1%) underwent major amputation. Perioperative mortality was 3.8%. After 24 months of follow-up study, the survival rate was 87.5%, whereas the limb salvage and graft patency rates were 76.02 and 49.17%, respectively. Pedal bypass with deep venous arterialization may be another therapeutic option to enhance the healing of ischemic ulcer and limb salvageability in patients with critical limb ischemia and unreconstructable distal artery.

Factors influencing the presence of peripheral arterial disease among Thai patients with type 2 diabetes

Background: Little is known about factors predicting peripheral arterial disease (PAD) development in Thai type 2 diabetes patients. This study aims to identify factors related to PAD in type 2 diabetes and the best predictors for PAD development. Methods and results: A case-control study was conducted in which 405 type 2 diabetes patients were recruited from four tertiary care hospitals in Bangkok, Thailand. Cases were type 2 diabetes patients with PAD who were compared to those without PAD. An ankle-brachial index (ABI) < 0.9 was used for PAD diagnosis. An ABI between 0.91 and 1.30 was used to define those without PAD. Demographic characteristics, the diabetes self-care activities score and chief complaints were measured. Thai type 2 diabetes patients with PAD were older (65.45 ± 12.2 years), had no formal schooling, and were more likely to be a local vendor than those without PAD (p < 0.05). Type 2 diabetes patients with PAD had diabetes longer than those without PAD (p < 0.05). Hypertension, coronary heart disease and chronic kidney disease were significantly more common in type 2 diabetes patients with PAD than those without PAD (p < 0.05). Age > 70 years, having coronary heart disease as a comorbid illness, and having a body mass index of 25–29.9 kg/m2 were predictive for PAD development (all p < 0.05). These three variables explained 12.3% of the variance in the incidence of PAD among type 2 diabetes patients. The demographic and clinical factors were the best predictors for PAD development. Conclusion: Thai type 2 diabetes patients who are elderly, have coronary heart disease as a comorbid condition, or have a normal weight should be considered at risk for PAD development.

Endovenous radiofrequency thermal ablation and ultrasound-guided foam sclerotherapy in treatment of klippel-trenaunay syndrome.

INTRODUCTION Klippel-Trenaunay syndrome is composed of port-wine stain, limb hypertrophy and varicose veins. METHODS The two patients with Klippel-Trenaunay syndrome treated by endovenous radiofrequency thermal ablation and ultrasound-guided foam sclerotherapy of the abnormal veins was conducted. RESULTS Radiofrequency thermal ablation resulted in successful occlusion of the incompetent anterior accessory great saphenous vein. Moreover, ultrasound-guided foam sclerotherapy showed complete occlusion of the residual veins. At 6 month follow-up, both patients markedly decreased leg symptoms including pain, cramping, limb swelling, and bulging of veins. CONCLUSION Radiofrequency thermal ablation combined with foam sclerotherapy is a minimally invasive procedure alternative to the standard invasive surgery and can be the option for saphenous ablation in Klippel-Trenaunay syndrome patients.

Vascular pythiosis in a thalassemic patient presenting as bilateral leg ulcers

Human pythiosis is an emerging disease caused by Pythium insidiosum, a fungus-like aquatic organism. Clinical presentations can be classified into four types: (i) cutaneous/subcutaneous, (ii) ocular, (iii) vascular, and (iv) disseminated pythiosis. Serological tests such as immunodiffusion and immunochromotographic test are useful to make rapid diagnosis in cutaneous and vascular pythiosis. We report a case of 35 year-old male with vascular pythiosis of both legs, diagnosed by serology and molecular techniques.

Comparison of clinical prediction scores for the diagnosis of deep vein thrombosis in unselected population of outpatients and inpatients

Objectives The aim of this research was to compare the accuracy of the modified Wells, the Wells, the Kahn, the St. André, and the Constans score for the diagnosis of deep vein thrombosis of the lower limb in unselected population of outpatients and inpatients. Method The pretest of probability score was employed in consecutive 500 outpatients and inpatients with suspicion of deep vein thrombosis. All patients were examined with compression ultrasonography. Results Deep vein thrombosis was confirmed in 26.4%. In the unselected population of outpatients and inpatients, the accuracy of the modified Wells score and the Constans score was higher than other scores. Both scores were more accurate for the outpatients. There was no accurate score for the inpatient subgroup. Conclusions The modified Wells and the Constans score appear to be useful in the unselected population of outpatients and inpatients and particularly in the outpatient subgroup.

Use of customised pressure‐guided elastic bandages to improve efficacy of compression bandaging for venous ulcers

Compression bandaging is a major treatment of chronic venous ulcers. Its efficacy depends on the applied pressure, which is dependent on the skill of the individual applying the bandage. To improve the quality of bandaging by reducing the variability in compression bandage interface pressures, we changed elastic bandages into a customised version by marking them with circular ink stamps, applied when the stretch achieves an interface pressure between 35 and 45 mmHg. Repeated applications by 20 residents of the customised bandage and non‐marked bandage to one smaller and one larger leg were evaluated by measuring the sub‐bandage pressure.

A new pretest probability score for diagnosis of lower limb deep vein thrombosis in unselected population of outpatients and inpatients

Objective To develop a new pretest probability score for deep vein thrombosis (DVT) in unselected population of outpatients and inpatients. Methods The new score was developed using independent factors from 500 patients clinically suspected of leg DVT. The new score was validated in a second group of 315 patients. Results The score consists of four components: unilateral leg pain, confinement to bed, calf enlargement >3 cm compared with the other side, and previous venous thromboembolism. A score ≥2 indicated a high probability while a score <2 indicated low probability. The sensitivity and specificity of the new score were 71.60% and 79.49%, respectively. The area under the receiver operating characteristic curve for the new score was 0.79. The combination of a new score <2 and D-dimer level <500 µg/L had a negative predictive value of 96.43%. Conclusions Our new score was valid in an unselected population of outpatients and inpatients.

Factors influencing prehospital delay time among patients with peripheral arterial occlusive disease

Background: Only one-third of patients with peripheral arterial occlusive disease (PAOD) seek medical care after perceiving the symptoms of PAOD, and most PAOD patients only visit the physician when they develop ulceration and gangrene. Delay can result in lower extremity amputation and death within three years. The aim of this study was to predict prehospital delay time from sociodemographic characteristics and clinical characteristics, social support, knowledge about PAOD, depression and fear, and treatment-seeking behaviors among patients with PAOD. Method and results: Data were collected in three university hospitals in Bangkok, Thailand. A sample of 212 patients with PAOD who were newly diagnosed or diagnosed within the preceding four months was recruited into the study. Questionnaires and interviewing were used to collect data. Stepwise multiple regression analysis was performed to identify the factors influencing prehospital delay time. Significant determinants of prolonged prehospital delay time were male gender, low monthly income (less than 10,000 Thai baht or 213 Euros), high level of perceived social support, and several treatment seeking behaviors. Depression, high level of fear, and self-pay of medical expenses were associated with short prehospital delay time. Overall, the model explained 41.0% of the variance in prehospital delay time. Conclusion: Clinicians need to develop intervention programs and national campaigns to increase knowledge about PAOD among patients in these high risk groups.

Comparative Study of the Management of Diabetic versus Nondiabetic Patients with Atherosclerosis Obliterans of the Lower Extremities

The aim of this study was to identify the influence of diabetes mellitus on patients with atherosclerosis obliterans (ASO) of the lower extremities. A prospective study was designed to compare differences between ASO patients with and without diabetes mellitus in regard to clinical characteristics and outcomes of management. Two hundred fifty-three consecutive (61.1%) diabetic and 161 (38.9%) nondiabetic patients were included in this study. Crural artery occlusion occurred more frequently in diabetic patients (tibioperoneal segment 26.5% vs 14.3%; p = .003). Diabetic patients had higher comorbidities, such as ischemic heart disease, disabling stroke, and renal failure. Infection requiring urgent surgical intervention was higher in diabetic patients (39.1% vs 24.2%; p = .001). This required primary major amputation in limb-threatening ischemia superimposed with infection (27.6% vs 17.7%; p = .037). The feasibility (67.2% vs 69.8%; p = .651) and success (74.4% vs 79.0%; p = .481) of revascularization between the two groups were comparable. Diabetic patients often needed more distal revascularization for limb salvage (34.4% vs 18.5%; p = .019). The mortality rate after revascularization was higher in diabetic patients (13.3% vs 2.5%; p = .009). Diabetes mellitus per se has no direct impact on limb salvageability in limb-threatening ischemia. The parity of feasibility and success in revascularization between the two groups should encourage attempts at limb salvage revascularization in diabetic patients.