Eric Wahlberg

Exercise in Patients with Intermittent Claudication Elicits Signs of Inflammation and Angiogenesis

OBJECTIVES Previous studies have demonstrated elevation of systemic levels of inflammatory cytokines after treadmill exercise in patients with intermittent claudication (IC), but it is unknown if growth factor expression also is stimulated. The aim of this study was to assess whether physical exercise-induced ischemia elicits an inflammatory response and increase in local and systemic vascular growth factor expression in patients with IC. METHODS Nineteen patients with IC had plasma concentrations of inflammatory markers (IL-6, TNF-alpha, hs-CRP) and vascular growth factors (VEGF and FGF-2) measured before and at four time points after a treadmill exercise test. In 10 patients a gastrocnemius muscle biopsy was obtained to measure VEGF and FGF-2 mRNA. Plasma concentrations of vWF were also measured. Five patients who underwent the treadmill test without experiencing calf pain were enrolled as controls. RESULTS Plasma concentrations of IL-6 increased after exercise (p=0.004), while TNF-alpha and hs-CRP were unchanged (p=0.191 and p=0.709, respectively). Plasma concentrations of VEGF were similar (p=0.151) at the different time points after exercise but FGF-2 levels decreased (p=0.013). In biopsies after treadmill testing VEGF-A mRNA was increased (p=0.043), but no change was observed for FGF-2 (p=0.456). CONCLUSION Exercise in IC triggers an inflammatory response as exemplified by elevated concentrations of IL-6. After exercise-induced pain, VEGF mRNA in calf muscle is increased. Therefore, it is plausible that angiogenesis is stimulated by exercise in IC.

Differences in presentation of symptoms between women and men with intermittent claudication

BackgroundMore women than men have PAD with exception for the stage intermittent claudication (IC). The purpose of this study was to evaluate differences in disease characteristics between men and women when using current diagnostic criteria for making the diagnosis IC, defined as ABI < 0.9 and walking problems.Study DesignCohort studyMethods5040 elderly (median age 71) subjects participated in a point-prevalence study 2004. They had their ABI measured and filled out questionnaires covering medical history, current medication, PAD symptoms and walking ability. The prevalence of IC was 6.5% for women and 7.2% for men (P = 0.09). A subset of subjects with IC (N = 56) was followed up four years later with the same procedures. They also performed additional tests aiming to determine all factors influencing walking ability.ResultsMen with IC had more concomitant cardiovascular disease and a more profound smoking history than women. Women, on the other hand, reported a lower walking speed (P < 0.01) and more joint problems (P = 0.018). In the follow up cohort ABI, walking ability and amount of atherosclerosis were similar among the sexes, but women more often reported atypical IC symptoms.ConclusionSex differences in the description of IC symptoms may influence diagnosis even if objective features of PAD are similar. This may influence accuracy of prevalence estimates and selection to treatment.

Acute Intestinal Ischemia

Acute intestinal ischemia is twice as common as a ruptured AAA There is a classic triad of symptoms: History of embolization Pain out of proportion Intestinal emptying When suspected, CT might make the diagnosis early enough to allow successful treatment If arterial obstruction—aggressive surgical or interventional treatment If venous obstruction—rarely surgical treatment Embolectomy is indicated if ischemia is diagnosed during laparotomy finding the jejunum to be normal

Acute Venous Problems

Thrombolysis is a viable treatment option for patients with deep vein thrombosis. Phlegmasia cerulea dolens may require surgical thrombectomy or thrombolysis as well as fasciotomy. Liberal use of cava filters may save patients from pulmonary embolism.

Vascular Injuries in the Upper Extremity

Suspect vascular injuries in patients with shoulder or elbow dislocation. When blood pressures in the arms differ, exclude vascular injuries in proximal arteries. It is usually the nerve injury that determines the functional outcome of arm injuries. Evaluate the brachial plexus and the median nerve function before and during vascular exploration. Repair of vascular injuries in the upper limb is wise even when ischemia appears to be limited.

Abdominal Vascular Injuries

Shock out of proportion to the extent of external injury suggests abdominal vascular injury. After the abdomen is entered, immediate control of the supraceliac aorta should be considered before continuing the operation. Retroperitoneal hematomas should not be explored right away unless they are actively bleeding. Stopping the procedure after the initial exploration for damage control to allow time for resuscitation in the intensive care unit is often a reasonable initial treatment. Endovascular methods such as aortic balloon occlusion, stent graft placement, and embolization of minor arteries are often effective measures for bleeding control.

Vascular Injuries to the Neck

Severe vascular injury after blunt neck trauma can be present even in the absence of clinical signs. Be liberal with CYA or duplex when cervical vessel injuries cannot be ruled out after blunt trauma. Associated injuries on the cervical spine, airway, and digestive tract must always be considered. Always stabilize the neck of patients in all types of severe cervical trauma until the entire spectrum of injuries is known. CTA or angiography should always be performed in penetrating injuries in zones I and III if the patient is stable. If available, CTA, duplex or angiography is recommended in zone II injuries in order to select patients for conservative versus surgical management.

Vascular Injuries in the Legs

Major bleeding is controlled by manual compression. In extremities with fractures, vascular injuries should always be suspected. Most vascular injuries are revealed by careful and repeated clinical examination. Before exploring a wound in a patient with a history of substantial bleeding, obtain proximal control.

Acute Leg Ischemia

It is important to evaluate the severity of ischemia. If the leg is immediately threatened, operation cannot be delayed. If the leg is viable, there is no benefit of an acute operation. Before the operation it is vital to consider the etiology of the occlusion, to be prepared to perform a distal vascular reconstruction if needed, and to treat heart and pulmonary failure if present.

Acute Problems with Vascular Dialysis Access

Infections in dialysis access fistulas can cause erosion and lethal bleedings. Infections in dialysis accesses should not be debrided in the emergency department. The urgency of revision of an occluded access depends on the patient’s need for dialysis and on available alternative dialysis options. Steal symptoms should be worked up urgently and treated expeditiously.