Livio Nakano

Predictive value of the ankle-brachial index in the evaluation of intermittent claudication

The purpose of this study was to determine whether the ankle-brachial index (ABI) could be used to predict the prognosis for a patient with intermittent claudication (IC). We studied 611 patients prospectively during 28 months of follow-up. We analyzed the predictive power of using various levels of ABI - 0.30 to 0.70 at 0.05 increments - in terms of the measures specificity (association with a favorable outcome after exercise rehabilitation therapy) and sensitivity (association with a poor outcome after exercise rehabilitation therapy). We found that using an ABI of 0.30 as a cut-off value produced the lowest margin of error overall, but the predictive power was still low with respect to identifying the patients with a poor prognosis after non-aggressive therapeutic treatment. Further study is needed to perhaps identify a second factor that could increase the sensitivity of the test.

Primary Utilization of Stents in Angioplasty of Superficial Femoral Artery

Percutaneous transluminal angioplasty (PTA) of infrainguinal arteries has been frequently reported in the literature. Independent of the technical feasibility, the results, in shortand long-term follow-up differ among published series. The objective of this article was to assess the long-term results of angioplasty in small, (<3 cm) segmental lesions of the superficial femoral artery treated with primary stenting. Eighteen patients (12 men, 6 women) with lesions of the superficial femoral artery smaller than 3 cm were selected for endovascular treatment and follow-up. The median patient age was 65 years (range, 54 to 84). The indication for treatment was intermittent claudication in 7 patients and critical ischemia (ischemic pain associated with trophic lesions) in 1 1 patients (62%). Of these, 13 lesions were stenoses and 5 total occlusions. The run-off was good in 15 patients who had more than 2 distal arteries and 3 had only 1 patent artery. During follow-up, all patients were observed with physical examination, progressive exercise treadmill test; pulse volume was measured with Doppler and duplex scan after 1, 3, and 6 months, and then twice a year. There was only 1 primary failure; the initial success rate was 94%. During follow-up of 40 months (6 to 70 months), only 1 patient presented with thrombosis of the stent 6 months after the procedure. There was no symptomatic restenosis in our study. One patient suffered an acute myocardial infraction after 45 months and died. The primary patency after 1 and 3 years was 88%. No patient was lost to follow-up. Primary stenting of segmental lesions (less than 3 cm) of the superficial femoral artery produced satisfactory results immediately and during long-term follow-up.

Endovascular treatment for intermittent claudication in patients who do not improve with clinical treatment

PURPOSE To study the results including long-term follow-up obtained with endovascular treatment of patients with intermittent claudication who did not experience clinical improvement with conservative treatment. METHODS From January 1992 to January 2002, 62 of 1380 patients (4.5%) with intermittent claudication underwent endovascular treatment and were followed up for up to 120 months (mean 76 months). The variables analyzed were the functioning of the arterial segment undergoing the endovascular procedure, the evolution of the maximum walking distance, and incidence of related morbidity and mortality. RESULTS Fifty-two patients (84%) experienced no walking limitation after the procedure, and 6 patients (10%) improved but still exhibited some degree of limitation, for a total improved outcome of 94%. The patency rate was 82%. There was no intraoperative mortality. One primary failure and one immediate thrombosis occurred, and both were surgically corrected. Thrombosis of the treated artery occurred in 6 patients 12, 16, 25, 29, 62, and 66 months after the procedure. These patients started to experience intermittent claudication with a walking distance to onset that was similar to their presurgical distance to onset. During follow-up, a mortality rate of 12.9% (8 patients) was observed, 6 due to myocardial infarctions and 2 due cerebral infarction. Three patients underwent coronary bypasses 22, 36, and 55 months after the endovascular surgery, and 2 patients underwent coronary angioplasty after 6 and 26 months. The mean follow up period was 76 months (range 0-120 months). CONCLUSION This study shows that endovascular treatment of intermittent claudication brought about a lasting regression of the ischemic conditions in a significant number of patients, with excellent patency rates. It was concluded that this is a good alternative for selected patients, with low rates of complications and positive long-term results.

Objective evaluation of upper limb claudication: use of isokinetic dynamometry

OBJECTIVE The objective of this work is to present an objective, practical, and reproducible method for evaluating the functional limitation caused by occlusive arterial disease in upper limbs: a stress test using an isokinetic dynamometer. METHODS Twenty-three patients with unilateral subclavian artery occlusive disease were included in the study, forming group 1. Seven patients of similar age, with atherosclerotic or Takayasus disease in the aorto-iliac segment, without subclavian artery occlusive disease, were included as a control group (group 2). For all tests, we utilized the CYBEX 6000 isokinetic dynamometer. The elbow was tested using a series of 30 repetitions of extension and flexion of the arm, performed up to a maximum of 270 repetitions (9 series) or until the limit of the tested limb was reached. RESULTS We initially compared all the limbs without arterial disease of both groups to analyze whether they presented similar functional performance. No significant difference was found for any of the parameters studied. Considering that upper limbs without arterial disease have a similar response to exercise in these analyzed parameters, we compared the upper limbs in group 1 (with and without subclavian artery occlusive disease). For all parameters, the limbs with subclavian artery occlusive disease presented significantly lower values than the control limbs (P < 0.05), which can be objectively attributed to the ischemia (there were different responses in different individuals, which allows the quantification of the limitation caused by subclavian artery occlusive disease). CONCLUSION In this study, we present a new stress test for impairment in patients with subclavian artery occlusive disease that might facilitate the classification of patients according to their functional impairment, and thus result in a better choice of therapeutic approach for each case as well as reporting of objective parameters that allow comparisons of the results of different treatments, including for long-term follow-up.

Tratamento cirúrgico para claudicação intermitente em pacientes que não melhoram com o tratamento clínico

OBJETIVO: Estudar prospectivamente os resultados obtidos com o tratamento cirurgico de portadores de claudicacao intermitente que nao obtiveram melhora clinica com o tratamento conservador, acompanhados, em media, por 6 anos. METODOS: De janeiro/1992 a janeiro/2002 foram acompanhados 26 pacientes tratados cirurgicamente de um grupo de 1380 portadores de claudicacao intermitente, admitidos num ambulatorio de doenca arterial obstrutiva periferica e claudicacao intermitente, representando 1,88% do total. RESULTADOS: Nao referiam limitacao para deambular apos a cirurgia 16 pacientes. Experimentaram melhora nove, porem com algum grau de limitacao, e dois, pequena melhora na distância maxima de marcha. Nao houve mortalidade intra-operatoria. Tres pacientes apresentaram trombose da arteria tratada 6,48 e 60 meses apos o procedimento e passaram a apresentar claudicacao intermitente para as distâncias previas a cirurgia. Durante o seguimento a longo prazo observamos uma mortalidade de 23,0% devido a infarto agudo do miocardio (4 casos), insuficiencia renal (um) e acidente vascular cerebral (um). Dois pacientes foram submetidos a revascularizacao do miocardio 2 e 4 anos apos a reconstrucao arterial e um ainda necessitou angioplastia coronariana com 3 anos de seguimento. O tempo de seguimento medio foi de 73 meses. CONCLUSAO: O tratamento cirurgico diminuiu sintomas isquemicos da claudicacao intermitente em muitos pacientes, com excelente taxa de patencia (88,4%) dos enxertos, tornando-se em pacientes que nao apresentam melhora com tratamento clinico, boa alternativa com baixas taxas de complicacoes e bons resultados a longo prazo.

Peroneal artery approach for angioplasty of the superficial femoral artery: a case report.

The authors report the implantation of a Palmaz stent in the superficial femoral artery using an approach not previously described, the peroneal artery. A 64-year-old man was admitted with extensive necrosis of the right foot. Physical examination showed a normal right femoral pulse but absence of popliteal and tibial pulses. Arteriography showed a superficial femoral artery with critical stenoses but a normal profunda artery. A classic below-knee amputation was performed. During the procedure, the muscular blood flow was considered insufficient, by clinical experience, to achieve limb healing at this level, and so the surgeon chose to perform an angioplasty of the superficial femoral artery lesion, utilizing an access through the leg arteries. After introducing the guidewire through the peroneal artery, the surgeon successfully dilated the lesion and implanted a Palmaz stent. Afterward, the popliteal pulse became palpable in physical examination and improved the skin and muscular aspect in this level. The surgery was finished with a closed stump. The surgery healed satisfactorily, without any complications, and the patient had a satisfactory follow-up, with ambulatory rehabilitation, and recovery of walking capacity with a leg prosthesis. The peroneal approach gave satisfactory results and should be considered in clinical situations like this.

Gadolinium Magnetic Angioresonance in the Study of Aortoiliac Disease

There is a need for noninvasive methods for the early identification of patients with intermit tent claudication who need surgical treatment. Newer magnetic resonance angiography (MRA)- techniques allow detailed study of the arterial tree with image quality similar to that of conven tional arteriography. From April 1997 to January 2001, 30 patients with intermittent claudica tion of the lower limbs were studied with both imaging methods. In each case, the MRA images were examined first and the arteriographic images were examined 15 days later. Examiners interpreting the arteriographic images were blinded to the results of the corresponding MRA images. After each examination (MRA and arteriography), a vascular surgeon suggested a surgical plan. MRA showed results similar to those of arteriography, although with inferior image quality. No patient had an allergic reaction or side effects due to administration of contrast material. There was total agreement between MRA and arteriography in regard to the morphologic analysis and proposed surgical plans in every case. In conclusion, MRA is a feasible, useful, and less invasive alternative for the morphologic evaluation of the aortofemoral area in patients with intermittent claudication of lower limbs.

Use of arteriography for the initial evaluation of patients with intermittent lower limb claudication

CONTEXT Many patients with intermittent claudication continue to be forwarded to the vascular surgeon for initial evaluation after arteriography has already been accomplished. OBJECTIVE The main objective of this work was to analyze the usefulness and the need for this procedure. TYPE OF STUDY Retrospective study. SETTING The patients were divided into two groups: Group 1, with the arteriography already performed and Group 2 without the initial arteriography. PARTICIPANTS One hundred patients with intermittent claudication were retrospectively studied. Other specialists had forwarded them for the first evaluation of intermittent claudication, without any previous treatment. MAIN MEASUREMENTS All patients were treated clinically for at least a 6-month period. The total number of arteriographies performed in the two groups was compared and the need and usefulness of the initial arteriography (of Group 1) was also analyzed. RESULTS The evolution was similar for both groups. The total number of arteriographies was significantly higher in Group 1 (Group 1 with 53 arteriographies vs. Group 2 with 7 arteriographies). For this group, it was found that arteriography was only useful in five cases (10%), because the surgeries were based on their findings. However, even in those cases, no need for arteriography was observed, as the procedure could have been performed at the time of surgical indication. CONCLUSION There are no indications for arteriography in the early evaluation of patients with intermittent claudication, because it does not modify the initial therapy, independent of its result. In cases where surgical treatment is indicated, this procedure should only be performed prior to surgery.

Infrarenal aortic aneurysm repair by retroperitoneal approach combined with laparoscopic cholecystectomy: Two case reports

Simultaneous repair of abdominal aortic aneurysm and treatment of cholelithiasis by the transperitoneal approach is controversial because of the risk of prosthesis infection. We report two patients who underwent a successful combined procedure using a retroperitoneal approach for the aortic aneurysm repair and a laparoscopic approach to the cholecystectomy. This combined approach reduces the risk of infection of the aortic prosthesis and is associated with a rapid return of normal peristalsis.

THE USE OF STENTS IN THE TREATMENT OF TRAUMATIC INTIMAL FLAPS: CASE REPORT

Treatment of arterial traumatic intimal lesions is controversial due to its unknown natural history. Current therapeutical options include arterial reconstruction and clinical observation. The idea of using stents to correct intimal flaps is based on their use to correct dissections, flaps, and arterial irregularities after angioplasty. We report the successful treatment of a traumatic intimal flap of the superficial femoral artery, caused by gunshot trauma, with a Palmaz stent in the acute period. One year after the operation, a duplex scan revealed normal flow in the artery and complete exclusion of the intimal flap; distal pulses were palpable, and the patient was completely asymptomatic.