Klara Belaj

Platelet-to-Lymphocyte Ratio: A Novel Marker for Critical Limb Ischemia in Peripheral Arterial Occlusive Disease Patients

Background Platelet-to-Lymphocyte Ratio (PLR) is an easily applicable blood test. An elevated PLR has been associated with poor prognosis in patients with different oncologic disorder. As platelets play a key role in atherosclerosis and atherothrombosis, we investigated PLR and its association with critical limb ischemia (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. PLR was calculated and the cohort was categorized into tertiles according to the PLR. An optimal cut-off value for the continuous PLR 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 PLR. As an optimal cut-off value, a PLR of 150 was identified. Two groups were categorized, one containing 1228 patients (PLR≤150) and a second group with 893 patients (PLR>150). CLI was more frequent in PLR>150 patients (410(45.9%)) compared to PLR≤150 patients (270(22.0%)) (p<0.001), as was prior myocardial infarction (51(5.7%) vs. 42(3.5%), p = 0.02). Regarding inflammatory parameters, C-reactive protein (median 7.0 mg/l (3.0–24.25) vs. median 5.0 mg/l (2.0–10.0)) and fibrinogen (median 457 mg/dl (359.0–583.0) vs. 372 mg/dl (317.25–455.75)) also significantly differed in the two patient groups (both p<0.001). Finally, a PLR>150 was associated with an OR of 1.9 (95%CI 1.7–2.1) for CLI even after adjustment for other well-established vascular risk factors. Conclusions An increased PLR is significantly associated with patients at high risk for CLI and other cardiovascular endpoints. The PLR is a broadly available and cheap marker, which could be used to highlight patients at high risk for vascular endpoints.

A high CHA2DS2-VASc score is associated with a high risk for critical limb ischemia in peripheral arterial occlusive disease patients

BACKGROUND The CHA(2)DS(2)-VASc (congestive heart failure, hypertension, age ≥ 75 years (doubled), type 2 diabetes, previous stroke, transient ischemic attack, or thromboembolism (doubled), vascular disease, age 65-75 years, and sex category) score was published as a predictive scoring model for stroke in atrial fibrillation patients. As multiple vascular risk factors are included in this score we evaluated the occurrence of critical limb ischemia (CLI) in peripheral arterial occlusive disease (PAOD) patients according to their CHA(2)DS(2)-VASc score independent of a coexisting atrial fibrillation. METHODS We evaluated 2237 PAOD patients treated at our institution from 2005 to 2010. CHA(2)DS(2)-VASc score was calculated and the occurrence of CLI was investigated. Furthermore all constituents of the score were investigated concerning association with CLI. RESULTS Frequency of CLI was higher in patients with a high CHA(2)DS(2)-VASc score. Age ≥ 75 years was associated with an increased risk for CLI (OR 3.0), as was age 65-75 years (OR 1.8), type 2 diabetes (OR 2.8), and the factor previous stroke, transient ischemic attack, or thromboembolism (OR 1.4). The occurrence of arterial hypertension was protective for CLI (OR 0.6). Sex and congestive heart failure were not associated with an increased CLI risk. CONCLUSION High CHA(2)DS(2)-VASc score is associated with a high CLI risk. As not all constituents are equally associated with CLI and some are even protective, a new score including only some of the factors should be evaluated for the prediction of CLI.

Exoseal for puncture site closure after antegrade procedures in peripheral arterial disease patients.

PURPOSE Exoseal is a vascular clo-sure device consisting of a plug applier and a bio-absorbent polyglycolic acid plug available in sizes 5 F, 6 F, and 7 F. In this study, we aimed to evaluate the effectiveness and safety of the Exoseal vascular closure device (Cordis Corporation, Bridgewater, New Jersey, USA) for puncture site closure after antegrade endovascular procedures in peripheral arterial occlusive disease (PAOD) patients. MATERIALS AND METHODS In this retrospective study, a total of 168 consecutive patients who underwent an interventional procedure due to PAOD, were included. In each case, an antegrade peripheral endovascular procedure was performed via the common femoral artery using the Seldinger technique, and Exoseal 5 F, 6 F, or 7 F was used for access site closure. The primary endpoint was a technically successful application of Exoseal. All complications at the access site within 24 hours were registered as a secondary endpoint. RESULTS In a group of 168 patients (64.9% men, average age 71.9±11.9 years), the technical application of Exoseal was successful in 166 patients (98.8%). Within the first 24 hours after the procedure, 12 complications (7.2%) were recorded including, three pseudoaneurysms (1.8%) and nine hematomas (5.4%). None of the complications required surgical intervention. CONCLUSION Exoseal is a safe and effective device with high technical success and acceptable complication rates for access site closure after antegrade peripheral endovascular procedures.

Primary antiphospholipid antibody syndrome—one further aspect of thrombophilia in overweight and obese patients with venous thromboembolism

Objective: Overweight and obesity are established risk factors for venous thromboembolism (VTE). We examined the difference in the frequency of primary antiphospholipid antibody syndrome (PAPS) in VTE patients according to their BMI.

Association of the Derived Neutrophil-Lymphocyte Ratio With Critical Limb Ischemia.

Neutrophil and leukocyte counts are laboratory parameters that reflect the systemic inflammatory response in patients with atherosclerotic diseases. Based on the means of these parameters, the derived neutrophil–lymphocyte ratio (dNLR) can be calculated. We investigated a possible association of critical limb ischemia (CLI) and the dNLR in patients with peripheral arterial disease (PAD). We performed a retrospective data analysis including 1995 patients with PAD treated at our department in the years 2005 to 2010. The cohort was divided into tertiles according to dNLR. Higher dNLR values were associated with an increased CLI rate. In the tertile with lowest dNLR, the CLI rate was 20.4%, in the second tertile the CLI rate was 26.1%, and in the third tertile the CLI rate was 36.1%. Statistical significance was shown using a Jonckheere-Terpstra test (P < .001). A high dNLR is associated with an increased rate of CLI in patients with PAD. This might be a useful parameter to highlight patients at increased risk of CLI.

Changes in lipid metabolism and extension of venous thromboembolism.

Background/Aims: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are common diseases with a vast number of acquired and congenital risk factors. Disorders of the lipid metabolism are not established risk factors for venous thromboembolism (VTE) so far. However, in recent literature, associations between VTE and the metabolic syndrome, especially with elevated lipid parameters, have been described. The aim of our study was to investigate the association between the extension of VTE and changes in the lipid profile. Methods: We included 178 VTE patients in our study; 59 patients had isolated PE, 39 patients had isolated DVT of the leg and 80 patients had both (DVT and PE). Concerning PE, we distinguished between massive and submassive PE. We evaluated plasma lipids and lipoproteins in PE and DVT patients as well as in massive and submassive PE patients. Results: PE patients had higher levels of plasma triglycerides [median (interquartile range): 162 (109-254) vs. 136.5 (96.5-162) mg/dl, p = 0.047] and lower levels of high-density lipoprotein cholesterol (HDL-C; 52.1 ± 17.2 vs. 63.9 ± 22.7 mg/dl, p = 0.004) than DVT patients. Furthermore, PE patients were significantly older than DVT patients (59.6 ± 16.9 vs. 52.2 ± 15.5 years, p = 0.02). We were not able to find differences in lipid parameters in patients with massive PE compared to those with submassive PE. However, patients with massive PE were more obese than patients with submassive PE (body mass index 29.1 ± 4.6 vs. 26.9 ± 4.9, p = 0.012). Conclusions: Lipid parameters and lipoproteins differ between DVT and PE patients. PE patients had higher triglyceride and lower HDL-C levels compared with DVT patients.

Graz Critical Limb Ischemia Score: A Risk Score for Critical Limb Ischemia in Peripheral Arterial Occlusive Disease.

AbstractCritical limb ischemia (CLI), a frequently encountered disorder, is associated with a high rate of limb amputation and mortality. To identify patients at high risk for CLI, we developed a simple risk score for peripheral arterial occlusive disease (PAOD).In our cross-sectional study, we first evaluated 1000 consecutive PAOD patients treated at our institution from 2005 to 2007, documenting clinical symptoms, comorbidities, and concomitant medication. We calculated odds ratios (OR) in a binary logistic regression model to find possible risk factors for CLI. We then verified the score in a second step that included the 1124 PAOD patients we treated between 2007 and 2011.In the first patient group, the greatest risk factors for CLI were age ≥75 years (OR 2.0), type 2 diabetes (OR 3.1), prior myocardial infarction (OR 2.5), and therapy with low molecular weight heparins (2.8). We scored 1 point for each of those conditions. One point was given for age between 65 and 75 years (OR 1.6) as well as for therapy with cardiac glycosides (OR 1.9) or loop diuretic therapy (OR 1.5). As statin therapy was protective for CLI with an OR of 0.5, we subtracted 1 point for those patients.In the second group, we could prove that frequency of CLI was significantly higher in patients with a high CLI score. The score correlated well with inflammatory parameters (c-reactive protein and fibrinogen). We were also able to define 3 different risk groups for low (score −1 to 1), intermediate (score 2–4), and high CLI risk (score >4).We developed a simple risk stratification scheme that is based on conditions that can be easily assessed from the medical history, without any laboratory parameters. This score should help to identify PAOD patients at high risk for CLI.

Prävention der venösen Thromboembolie

ZusammenfassungDie venöse Thromboembolie (VTE) – bestehend aus tiefer Beinvenenthrombose (TVT) und Pulmonalarterienembolie (PAE) – ist speziell bei chirurgischen Patienten eine häufige Komplikation. Es gibt daher auch in Abhängigkeit der durchgeführten Operation für diese Patienten klare Empfehlungen für eine postoperative Antikoagulation, um eine solche VTE zu verhindern. Auch bei internistischen Patienten ist die VTE häufig. Das VTE-Risiko variiert je nach Begleiterkrankungen des Patienten und kann mit speziellen Scores erhoben werden. Die Indikation zur Thromboseprophylaxe wird in Abhängigkeit des individuellen VTE- und Blutungsrisikos gestellt. Ein besonders thrombophiles Patientenkollektiv stellt jenes der Tumorpatienten dar. Bei diesen ist das VTE-Risiko als sehr hoch einzuschätzen. Speziell postoperativ ist daher bei diesen Patienten eine längere Phase der Antikoagulation anzustreben.Ziel dieses Reviews ist es, eine Kurzübersicht über aktuelle Empfehlungen zur Thromboseprophylaxe in den oben ausgeführten Indikationen zu geben.AbstractVenous thromboembolism (VTE), which consists of deep vein thrombosis (DVT) and pulmonary embolism (PE), is a frequent complication especially in surgical patients. Therefore, recommendations are clearly in favor of postoperative anticoagulation to prevent VTE in surgical patients, depending on the surgical procedure performed. A VTE is also frequently found in internal medical patients; however, the risk of VTE varies depending on the comorbidities of the patient. Therefore, there are scoring systems to support the evaluation of the individual risk of VTE as well as the risk of bleeding. A group of patients that has a very high risk for VTE is cancer patients. Especially after surgery, a longer period of anticoagulation is mandatory for these patients. The aim of this review is to summarize the most important issues and recommendations for VTE prophylaxis in surgical, medical and cancer patients.

Progressive jugular vein thrombosis in cutaneous extramedullary plasmacytoma

A 67-yr-old woman with a 5-yr history of idiopathic thrombosis in the right internal jugular vein presented at our department with progressive skin lesions in her face, progressive thrombosis in the right internal jugular vein, and a newly found thrombosis in the left internal jugular vein despite sufficient oral anticoagulation. Monoclonal gammopathy of undetermined significance IgG lambda was diagnosed 5 yr prior to admission. Physical examination revealed massive vein convolutes spread from head over neck to the chest. Bone marrow biopsy showed no pathological findings. Magnetic resonance venography showed massive soft tissue expansion in the face with low contrast enhancement infiltrating the wall of superior caval vein and reaching the right atrium in the form of a cone. Upon this structure, appositional thrombus formation was found. Punch biopsy samples taken from maculous skin lesions in the face clinically suspicious of angiosarcoma revealed vascular malformation without evidence for malignancy. To get a more representative specimen, deep biopsy was carried out. Histology showed a cutaneous plasmacytoma expressing IgG lambda. Chemotherapy with Dexamethason, Doxorubicin, and Bortezomib was scheduled. Before specific treatment was started, the patient died of acute heart failure. Autopsy showed no evidence of acute pulmonary embolism, but tumor thrombi in both jugular veins and the superior caval vein with an extension up to 19 centimeters. In the face and neck, an extended cutaneous tumor infiltration could be found. The bone marrow showed no evidence of infiltration. Accordingly, the patient suffered from a primary cutaneous manifestation of an extramedullary plasmacytoma (Fig. 1). Cutaneous plasmacytomas are frequently diagnosed in dogs with an excellent prognosis (1). In humans, extramedullary cutaneous plasmacytomas are scarce and little is known about treatment and progression of this malignant plasma cell tumor. Remarkable 5-yr survival rates (93–98%) for primary extramedullary plasmacytomas involving skin and lymph nodes were published recently (2). To make this rare diagnosis, deep tissue biopsy is indispensable which reveals the characteristic pattern of densely packed atypical plasma cells in the absence of coexistent myelomatous bone marrow disease (3).