Ramesh Velu

Association of impaired fasting glucose, diabetes and their management with the presentation and outcome of peripheral artery disease: a cohort study

BackgroundPre-diabetes and untreated diabetes are common in patients with peripheral artery disease however their impact on outcome has not been evaluated. We examined the association of impaired fasting glucose, diabetes and their treatment with the presentation, mortality and requirement for intervention in peripheral artery disease patients.MethodsWe prospectively recruited 1637 patients with peripheral artery disease, measured fasting glucose, recorded medications for diabetes and categorised them by diabetes status. Patients were followed for a median of 1.7 years.ResultsAt entry 22.7% patients were receiving treatment for type 2 diabetes by oral hypoglycaemics alone (18.1%) or insulin (4.6%). 9.2% patients had non-medicated diabetes. 28.1% of patients had impaired fasting glucose (5.6-6.9 mM). Patients with non-medicated diabetes had increased mortality and requirement for peripheral artery intervention (hazards ratio 1.62 and 1.31 respectively). Patients with diabetes prescribed insulin had increased mortality (hazard ratio 1.97). Patients with impaired fasting glucose or diabetes prescribed oral hypoglycaemics only had similar outcomes to patients with no diabetes.ConclusionsNon-medicated diabetes is common in peripheral artery disease patients and associated with poor outcomes. Impaired fasting glucose is also common but does not increase intermediate term complications. Peripheral artery disease patients with diabetes requiring insulin are at high risk of intermediate term mortality.

Use of a covered stent to treat two large false aneurysms of the anterior tibial artery.

A 42-year-old man was admitted to hospital complaining of a pulsatile swelling in the anterior compartment of his left lower leg. One month earlier, he had been stabbed in that area with a small knife but had not sought medical attention at that point. His medical history included diabetes mellitus and a right below knee amputation. The clinical examination revealed a large swelling in the anterior compartment of the left lower leg. All pulses were palpable in the left leg except the dorsalis pedis. Arterial duplex imaging and an angiogram demonstrated two large false aneurysms arising from the anterior and posterior wall of left anterior tibial artery (A and Cover). Through an antegrade approach by way of the left common femoral artery, a 6F sheath was negotiated into the left popliteal artery. Over a 0.035-inch wire, selective catheterization of the anterior tibial artery was undertaken, and the catheter was placed distal to the false aneurysm. Intra-arterial heparin was administered (4000 units). The catheter was exchanged for a 0.0140-inch wire, and a 3-mm 19-mm covered stent (JOSTENT Graft, Abbott Vascular, Abbott Park, Ill) was placed at the site of the false aneurysm. Residual filling of the aneurysm was demonstrated. A further 3.5-mm 19-mm overlapping covered stent was placed and achieved complete exclusion of the aneurysm (B and C). The patient was discharged the next day without complication. At follow-up 6 weeks later, the mass in the left anterior compartment was nonpulsatile and reducing in size. Both pedal pulses were palpable.

Serum homocysteine is associated with the severity of primary chronic venous disease

Objective This study was conducted to assess whether serum homocysteine concentration was associated with the severity of primary chronic venous disease. Design Cross-sectional study. Methods A total of 282 primary chronic venous disease patients were enrolled from outpatient vascular services. The severity of venous disease was graded using the Clinical Etiology Anatomy Pathophysiology classification system. The association of serum homocysteine concentration with advanced primary chronic venous disease (C4-6) was assessed using the Mann Whitney U test and logistic regression analysis. Results Median (interquartile range) serum homocysteine concentrations were 9.10 µM (7.55–10.75) and 10.40 µM (8.85–13.10) in patients with primary chronic venous disease classified by C1-3 (n = 209) and C4-6 (n = 73) grades, respectively, p < 0.001. Serum homocysteine concentration was positively associated with clinical grade 4–6 after adjusting for other risk factors including age, diabetes, male sex, hypertension, recurrent varicose veins and stroke. Patients with serum homocysteine in the third (odds ratio, 2.76, 95% confidence interval, 1.01–7.54) and fourth (odds ratio 3.29, 95% confidence interval 1.15–9.43) quartiles were more likely to have grade C4-6 chronic venous disease than subjects with serum homocysteine in the first quartile. Conclusions Serum homocysteine is positively associated with the severity of primary chronic venous disease and therefore could play a role in promoting chronic venous disease complications.

Paclitaxel-coated balloon reduces target lesion revascularization compared with standard balloon angioplasty

Objective: Peripheral arterial disease (PAD) is a highly prevalent condition that contributes significantly to the morbidity and mortality of affected patients. PAD creates a significant economic burden on health care systems around the world. We reviewed all available literature to provide a meta‐analysis assessing the outcome of patients treated with drug‐eluting balloons (DEBs) compared with percutaneous transluminal balloon angioplasty (PTA) through measuring the rate of target lesion revascularization (TLR). Methods: An electronic search of the MEDLINE, Scopus, Embase, Web of Science, and Cochrane Library databases was performed. Articles reporting randomized controlled trials that compared treatment with DEBs vs PTA were selected for inclusion. A meta‐analysis was performed by pooling data on rates of TLR, binary restenosis (BR), and late lumen loss (LLL). Results: The 10 included articles comprised a sample size of 1292 patients. Meta‐analysis demonstrated the rate of TLR in DEB‐treated patients was significantly lower compared with patients treated with PTA at 6 months (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.11‐0.53; P = .0004), 12 months (OR, 0.28; 95% CI, 0.13‐0.62; P = .002), and 24 months (OR, 0.25; 95% CI, 0.10‐0.61; P = .002). Decreased LLL and BR was demonstrated at 6 months in patients treated with DEBs compared with patients treated with PTA (mean difference, −0.74; 95% CI, −0.97 to −0.51; P = .00001; OR, 0.34; 95% CI, 0.23‐0.49; P = .00001). Conclusions: This meta‐analysis demonstrates that treatment with DEBs compared with PTA results in reduced rates of reintervention in patients with PAD. Comparison of DEBs to other emerging treatments to determine which method results in the lowest reintervention rates and in the greatest improvement in quality of life should be the focus of future trials.

A comparison of major amputation rates and outcomes for Indigenous and non-Indigenous Australians in a major tertiary hospital

ISSN: 2573-4482 Statement of the Problem: Nuclear factor (erythroid-derived 2)like 2 (NRF2) is a global antioxidant gene inducer whose activity may regulate metabolism of extracellular matrix proteins including collagen. It was shown that human abdominal aortic aneurysm has increased deposition of collagen I and reduced of collagen III in tunica media and adventitia. The synthesis of collagen I is controlled by transforming growth factor beta 1 (TGFb1). Therefore, the purpose of this study was to describe localization of structural collagens within the aorta and aortic aneurysm in transcriptional knockouts of Nrf2 and to verify the mechanism behind those changes.Methods: Five hundred and seventy two cases (576 stents, open or closed-cell stents) who underwent CAS from January 2013 to December 2015 were retrospectively enrolled in this study. The location of carotid stenosis (common carotid artery or internal carotid artery), characteristics of plaques (regular morphology or not; with calcification or not), the length of stent, types of carotid stent (closed or open cell), rate of stent expansion (ratio of radial expansion and axial expansion) were detected one month before and one week after stenting by CDFI. Residual stenosis is defined as the stenosis rate is equal to or greater than 30% by DSA immediately after stenting.ISSN: 2573-4482 E dysfunction (ED) concomitant with psychosis is common in adults younger than 30 years. Most cases are con-sidered entirely psychogenic in nature. Given that penile erection-related veins constitute the principal components in erectile rigidity in defrosted cadaveric he-modynamic studies; do venogenic factors dominate psychogenic factors in males with ED? Although phospho-di-esteraser-5 inhibitors have clarified current ED medi-cal treatment, resulting in a consensus on ED pathophysiology, the understanding of the erection process may yet be just at a fledgling stage. Clinically, the psychological factor plays a significant role because placebo effect affects approximately 40% of participants in clinical trials. Based on a novel penile venous anatomy and physio-logical osmolality and viscosity, an apa-gogical hemodynamic study was conducted on defrosted cadavers. Implying penile veins themselves are the most crucial fac-tors in erection physiology and that obvi-ously venogenic factors are inappropriately considered cavernosal factor in the list of ED contributors. According to our vast clinical experience, the penile venous stripping method proves to be an exclusive and naturally viable treatment option. The term young ED refers to males with ED who is younger than 40 years, whereas it strictly referred to males younger than 30 years in the three publications in our evi-dence based report. Those young ED males account for 10.3% (35/341) to 14.3% (5/35) (average, 12.1%) of the total patients with ED who underwent penile venous stripping. Erectile function is the seamless interplay of psychological and physiological health in adult males. Penile erection related veins play a principal role in erectile rigidity in cadaveric hemody-namic studies, and venoocclusive dys-function is prevalent in males with ED. However, psychological factors contribute some extent in ED and they should not be ignored during ED treatment. The role of the contribution also cannot be underesti-mated in impotence in males younger than 30 years. Figure 1: Excessive penile veins in impo-tent male younger than 30 years. (A) In this 29-year-old man, a 30°, oblique-view cavernosogram discloses extraordinary excessive penile veins which ought to be the cause of primary impotence. The first set of dual cavernosogram (anteri-or−posterior view) is obtained while a 10-ml diluted iohexol solution is intracavern-ously injected via a 19 G scalp needle. The preprostatic plexus shows immediately with the contrast medium. Rapid filling of the internal pudendal and then to internal iliac veins. Implies the drainage veins of the cavernosal sinusoids is tremendously speedy. (B) An oblique view of the phar-macocavernosogram documents the veno-occlusive dysfunction despite a rigid erec-tion ensues. The prostaglandin E1 is in-tracavernously injected via the same needle

Vascular Surgical Practice in North Queensland, Australia

North Queensland, for the purpose of this chapter encompasses a wide area of the state of Queensland, north of Rockhampton and extends west up to Mt Isa. This region is much bigger than many countries. The population according to 2010 data is around 720,000. Within Australia, the indigenous population comprises of mainly aboriginal Australians (approximately 500,000) and Torres Strait Islander (approximately 35,000). Nearly two-thirds (64 %) of Australia’ Torres Strait Islander population and about a quarter (24.8 %) of Australia’s Aboriginal population were living in Queensland at the time of the 2011 Census. 41.5 % of these people were in the three Indigenous regions of North Queensland, mainly Cairns-Atherton, Townsville-Mackay and Rockhampton (Fig. 45.1).

Circulating biomarkers are not associated with endoleaks after endovascular repair of abdominal aortic aneurysms

OBJECTIVE Endoleak is a common complication of endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) but can be detected only through prolonged follow-up with repeated aortic imaging. This study examined the potential for circulating matrix metalloproteinase 9 (MMP9), osteoprotegerin (OPG), D-dimer, homocysteine (HCY), and C-reactive protein (CRP) to act as diagnostic markers for endoleak in AAA patients undergoing elective EVAR. METHODS Linear mixed-effects models were constructed to assess differences in AAA diameter after EVAR between groups of patients who did and did not develop endoleak during follow-up, adjusting for potential confounders. Circulating MMP9, OPG, D-dimer, HCY, and CRP concentrations were measured in preoperative and postoperative plasma samples. The association of these markers with endoleak diagnosis was assessed using linear mixed effects adjusted as before. The potential for each marker to diagnose endoleak was assessed using receiver operating characteristic curves. RESULTS Seventy-five patients were included in the study, 24 of whom developed an endoleak during follow-up. Patients with an endoleak had significantly larger AAA sac diameters than those who did not have an endoleak. None of the assessed markers showed a significant association with endoleak. This was confirmed through receiver operating characteristic curve analyses indicating poor diagnostic ability for all markers. CONCLUSIONS Circulating concentrations of MMP9, OPG, D-dimer, HCY, and CRP were not associated with endoleak in patients undergoing EVAR in this study.

Asymptomatic mirror right aortic arch

[Extract] An asymptomatic right aortic arch with mirror configuration including a left innominate artery was incidentally identified on computed tomography (CT) neck angiogram of a 78-year-old male patient following transient ischaemic attack.

Partial descending thoracic aortic replacement for chronic Type B dissection

Repair of chronic Type B aortic dissection can be technically challenging. Here we describe a technique for the partial replacement of the descending thoracic aorta that minimises operative risk and avoids full replacement of the thoraco-abdominal aorta. This approach can be considered when there is heterogeneous perfusion of abdominal viscera by the true and false lumens of the chronically dissected aorta.