Ernst Pilger

Neutrophil-to-lymphocyte ratio and its association with critical limb ischemia in PAOD patients.

Background The Neutrophil-to-Lymphocyte ratio (NLR) is an easy to perform test from the white blood cell count. An increase in NLR has been associated with vascular endpoints reflecting inflammation in atherosclerotic lesions. Atherosclerosis is a global threat and vascular endpoints, like myocardial infarction or critical limb ischemia (CLI), are a leading cause of death in industrialized countries. We therefore investigated NLR and its association with CLI and other vascular endpoints in peripheral arterial occlusive disease (PAOD) patients. Methods and Findings We evaluated 2121 PAOD patients treated at our institution from 2005 to 2010. NLR was calculated and the cohort was divided into tertiles according to the NLR. An optimal cut-off value for the continuous NLR was calculated by applying a receiver operating curve analysis to discriminate between CLI and non-CLI. In our cohort occurrence of CLI significantly increased with an increase in NLR. As an optimal cut-off a NLR of 3.95 was identified. Two groups were categorized, one containing 1441 patients (NLR≤3.95) and a second group with 680 patients (NLR>3.95). CLI was more frequent in NLR>3.95 patients (330(48.5%)) compared to NLR≤3.95 patients (350(24.3%)) (p<0.001), as were prior myocardial infarction (48(7.0%) vs. 47(3.3%), p<0.001) and stroke (73(10.7) vs. 98(6.8%), p<0.001). Regarding other inflammatory parameters, C-reactive protein (median 5.6 mg/l (2.3–19.1) vs. median 3 mg/l (1.5–5.5)) and fibrinogen (median 412 mg/dl (345.5–507.5) vs. 344 mg/dl (308–403.5)) also significantly differed in the two patient groups (both p<0.001). A NLR>3.95 was associated with an OR of 2.5 (95%CI 2.3–2.7) for CLI even after adjustment for other vascular risk factors. Conclusions An increased NLR is significantly associated with patients at high risk for CLI and other vascular endpoints. The NLR is an easy to perform test, which could be used to highlight patients at high risk for vascular endpoints.

Asymptomatic deep vein thrombosis and superficial vein thrombosis in ambulatory cancer patients: impact on short-term survival

Background:Asymptomatic venous thrombotic events (VTEs) are possible findings in ambulatory cancer patients. Data regarding the incidence and clinical impact of asymptomatic VTEs are conflicting. We therefore conducted a study to evaluate the occurrence of asymptomatic VTEs of the lower limbs in ambulatory cancer patients to further evaluate the association of these asymptomatic VTEs on survival during a 9-month follow-up period.Methods:In our prospective cohort, we included 150 consecutive ambulatory cancer patients who were free of any clinical symptoms for VTEs. Compression ultrasound to detect deep vein thrombosis (DVT) and superficial venous thrombosis (SVT) of the lower limbs was performed by a vascular specialist in all patients at baseline. In case of pathological findings the patients were treated with low molecular weight heparin (LMWH) because of current established guidelines. The occurrence of death was investigated during a 9-month follow-up period.Results:A total of 27 (18%) patients with VTEs were detected, which included 13 patients (8.7%) with a SVT and 16 patients (10.7%) showing a DVT. Two patients had both, a SVT and a DVT as well. During the 9-month follow-up period the occurrence of a VTE at baseline was associated with a 2.4-fold increased risk for death (HR 2.4 (1.2–5.3); P=0.03).Conclusion:Asymptomatic VTEs of the lower limbs in ambulatory cancer patients are frequently occurring concomitant features and are associated with poor survival during a 9-month follow-up period despite anticoagulation with LMWH.

Neointimal Hyperplasia after Silverhawk Atherectomy versus Percutaneous Transluminal Angioplasty (PTA) in Femoropopliteal Stent Reobstructions: A Controlled, Randomized Pilot Trial

BackgroundDue to intimal hyperplasia instent reobstruction in the femoropopliteal arterial segment is still an unsolved problem. Different techniques have been discussed in case of reintervention to guarantee longlasting patency rate.MethodsWe conducted a randomized, controlled, pilot trial comparing Silverhawk atherectomy with percutaneous transluminal angioplasty (PTA) in patients with a first instent reobstruction in the femoropopliteal arterial segment, to evaluate intima media thickness (IMT) within the treated segment, as a parameter of recurrence of intimal hyperplasia.ResultsIn a total 19 patients were included: 9 patients in the atherectomy device and 10 patients in the PTA arm. IMT within the treated segment was statistically significantly elevated in all patients treated with the Silverhawk device versus the patients treated with PTA. The obvious differentiation in elevation of IMT in nonfavor for patients treated with the Silverhawk device started at month 2 (max IMT SH 0.178xa0mm vs. IMT PTA 0.1xa0mm, pxa0=xa00.001) with a spike at month 5 (max IMT SH 0.206xa0mm vs. IMT PTA 0.145xa0mm, pxa0=xa00.003) and a decline once again at month 6 (max IMT SH 0.177xa0mm vs. IMT PTA 0.121xa0mm, pxa0=xa00.02). The values for mean IMT performed the same way.ConclusionsAlthough Silverhawk atherectomy provides good results at first sight, in the midterm follow-up of treatment of first instent restenosis it did not perform better than PTA as it showed elevated reoccurrence of intimal media hyperplasia.

Regulatory T cells improve nephrocalcinosis but not dystrophic cardiac calcinosis in DBA/2 mice.

Nephrocalcinosis is characterized by aberrant deposition of calcium in the kidneys and is seen in phosphate nephropathy, primary hyperparathyroidism, and distal renal tubular acidosis. To further evaluate the specific pathophysiologic role of T cells in ectopic calcification, we used DBA/2 mice that are prone to develop nephrocalcinosis and dystrophic cardiac calcinosis. Female DBA/2 mice were depleted of T cells (n = 10) or regulatory T cells (Tregs) (n = 15) using either an anti-CD3ɛ or an anti-CD25 monoclonal antibody and compared with isotype-treated controls (n = 9; n = 15), respectively. After this immunomodulation, the DBA/2 mice were given a high-phosphate diet for 9 days and the degree of calcification was assessed by microcomputed tomography. Successful depletion was confirmed by flow cytometry of splenocytes. In DBA/2 mice, the high-phosphate diet induced a phenotype of nephrocalcinosis and dystrophic cardiac calcinosis. T-cell depletion significantly increased renal calcification in microcomputed tomography (P = 0.022). Concordantly, Treg depletion significantly deteriorated acute phosphate nephropathy (P = 0.039) and was associated with a significantly increased mortality rate (P = 0.004). Immunomodulation had no impact on the amount of cardiac calcification. Semiquantitative histopathologic evaluations with Alizarin Red staining independently confirmed the respective radiologic measurements. In summary, our data suggest a pivotal role of Txa0cells, particularly Tregs, in the progression of nephrocalcinosis and emphasize the fact that inflammation deteriorates the outcome in acute phosphate nephropathy.

Lipoproteins and the Development of Restenosis After Stent Implantation in the Superficial Femoral Artery in Patients with Peripheral Artery Disease

PurposeHigh levels of apolipoprotein B (apo B) are a risk factor for the development of major vascular events. We evaluated the association between plasma lipoproteins and the development of superficial femoral artery (SFA) in-stent restenosis and reocclusion in patients with peripheral artery disease.Materials and MethodsWe included 139 patients with SFA stenting. Plasma lipoproteins were measured after stent implantation. Stent restenosis was assessed with duplex scan after 3, 6, and 12xa0months. A stenosis grade was considered relevant if >50%.ResultsSeventy-two patients experienced recurrence of their atherosclerotic disease, meaning restenosis of >50% within 1xa0year of follow-up. Ten of these patients had a stent occlusion. In the patients who experienced recurrence, the mean apo B level was 105.8 versus 94.9xa0mg/dl in patients without recurrence (Pxa0<xa00.05). Patients without recurrence had higher high-density lipoprotein cholesterol levels than patients with recurrence (39.7 vs. 34.7xa0mg/dl, Pxa0<xa00.05). Comparing patients with a stent occlusion (nxa0=xa010) and those with a restenosis of 75–99% (nxa0=xa028), the patients with a stent occlusion had higher levels of plasma cholesterol (234.1 vs. 185.9xa0mg/dl, Pxa0<xa00.05), apo B (135.3 vs. 99.8xa0mg/dl, Pxa0<xa00.05), low-density lipoprotein cholesterol (160.3 vs. 113.6xa0mg/dl, Pxa0<xa00.05), and low-density lipoprotein apo B (115.5 vs. 82.4xa0mg/dl, Pxa0<xa00.001) than the patients with restenosis of 75–99% (nxa0=xa028).ConclusionChanges in the lipid profile could be one reason for the development of restenosis and for the development of reocclusion after SFA stenting.

Are flow-mediated vasodilatation and intima-media thickness of the brachial artery associated with restenosis after endovascular treatment of peripheral arterial occlusive disease?

Objective:Restenosis after percutaneous angioplasty of peripheral arteries is still an unsolved matter. Previous studies reported an association between flow-mediated dilatation (FMD), a marker of endothelial dysfunction, and restenosis after coronary angioplasty. This study evaluates the influence of FMD and brachial intima-media thickness (B-IMT) on restenosis after angioplasty of peripheral arteries.Methods:One hundred and eighty-four patients (124 male) with claudication related to peripheral arterial disease participated in this trial. FMD and B-IMT were assessed before endovascular revascularisation. In a 12-month follow-up duplex ultrasound examinations were performed to detect restenosis. Finally 128 patients (91male, 37 female) were eligible for statistical analysis.Results:Restenosis was found in 54 patients (42.2%). Mean FMD was 3.53u2009±u20093.56%, with no difference between the patients with restenosis (3.55u2009±u20093.64%) and those without (3.52u2009±u20093.48%; pu2009=u20090.716). B-IMT had a mean value of 0.326u2009±u20090.134xa0mm. B-IMT significantly differed between the patients with restenosis (0.326u2009±u20090.134xa0mm) and those without (0.256u2009±u20090.133xa0mm; pu2009=u20090.007). We confirmed that a B-IMT over 0.21xa0mm was an independent risk factor for restenosis [OR 2.9 (1.3–6.3)].Conclusion:Endothelial dysfunction is not associated with restenosis. Conversely patients with enlarged B-IMT are at risk of restenosis after angioplasty of peripheral arteries.

Austrian Lipid Consensus on the management of metabolic lipid disorders to prevent vascular complications: A joint position statement issued by eight medical societies. 2016 update.

SummaryIn 2010, eight Austrian medical societies proposed axa0joint position statement on the management of metabolic lipid disorders for the prevention of vascular complications. An updated and extended version of these recommendations according to the current literature is presented, referring to the primary and secondary prevention of vascular complications in adults, taking into consideration the guidelines of other societies. The “Austrian Lipid Consensusxa0–xa02016xa0update” provides guidance for individualized risk stratification and respective therapeutic targets, and discusses the evidence for reducing vascular endpoints with available lipid-lowering therapies. Furthermore, specific management in key patient groups is outlined, including subjects presenting with coronary, cerebrovascular, and/or peripheral atherosclerosis; diabetes mellitus and/or metabolic syndrome; nephropathy; and familial hypercholesterolemia.ZusammenfassungIm Jahr 2010 haben acht österreichische Fachgesellschaften eine gemeinsame Stellungnahme zum Management von Fettstoffwechselstörungen für die Prävention vaskulärer Komplikationen erarbeitet. Für die vorliegende Neuauflage wurden diese Empfehlungen nach aktueller Studien- und Literaturlage überarbeitet und erweitert und Richtlinien anderer Fachgesellschaften berücksichtigt. Der „Österreichische Lipidkonsensus 2016“ bezieht sich auf das Lipidmanagement im Rahmen der vaskulären Primär- und Sekundärprävention bei Erwachsenen. Er gibt Anleitungen für die individuelle Risikostratifizierung und die daraus abgeleiteten Behandlungsziele und diskutiert die Evidenz hinsichtlich der Reduktion vaskulärer Endpunkte durch die verfügbaren lipidsenkenden Therapien. Des Weiteren wird auf das spezifische Lipidmanagement bei wichtigen Patientengruppen, darunter Personen mit koronarer, zerebrovaskulärer und/oder peripherer Atherosklerose, Diabetes mellitus und/oder metabolischem Syndrom, Nephropathie sowie familiärer Hypercholesterinämie eingegangen.

Foreign body pulmonary embolism

SummaryWe report a case of a foreign body embolism caused by a tip of an explanted port-a-cath system. The embolus could be removed with a gooseneck snare catheter, the patient fully recovered.ZusammenfassungWir berichten den Fall einer Fremdkörper-Pulmonalarterienembolie, ausgelöst durch die Spitze eines zuvor explantierten Port-a-cath-Systems. Der Embolus konnte mittels ‚GooseNeck Snare‘ –Katheter vollständig und komplikationslos entfernt werden.