1/81. University of Miami Division of Clinical pharmacology Therapeutic Rounds: ischemic renal disease.Ischemic renal disease (IRD) is defined as a significant reduction in glomerular filtration rate and/or loss of renal parenchyma caused by hemodynamically significant renal artery stenosis. IRD is a common and often overlooked clinical entity that presents in the setting of extrarenal arteriosclerotic vascular disease in older individuals with azotemia. IRD is an important cause of chronic renal failure and end-stage renal disease (ESRD), and many patients with a presumed diagnosis of hypertensive nephrosclerosis may actually have undiagnosed ischemic nephropathy as the cause of their ESRD. The primary reason for establishing the diagnosis of IRD is the hope that correction of a renal artery stenosis will lead to improvement of renal function or a delay in progression to ESRD. There are six typical clinical settings in which the clinician could suspect IRD: acute renal failure caused by the treatment of hypertension, especially with angiotensin-converting enzyme inhibitors; progressive azotemia in a patient with known renovascular hypertension; acute pulmonary edema superimposed on poorly controlled hypertension and renal failure; progressive azotemia in an elderly patient with refractory or severe hypertension; progressive azotemia in an elderly patient with evidence of atherosclerotic disease; and unexplained progressive azotemia in an elderly patient. It is important for the clinician to identify IRD, because IRD represents a potentially reversible cause of chronic renal failure in a hypertensive patient.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |
2/81. Embolized ischemic lesions of toes in an afibrinogenemic patient: possible relevance to in vivo circulating thrombin.Fibrinogen plays a complex role in hemostasis, thrombosis, and vascular disease. Hyperfibrinogenemia is an independent vascular risk factor and dysfibrinogenemia can provoke thrombosis. afibrinogenemia is usually responsible for hemorrhagic diathesis, and unexpected ischemic lesions are intriguing. We report the case of an afibrinogenemic patient, who at the age of 30 developed ischemic lesions of the feet related to severe stenosis of the iliac and hypogastric arteries. The biopsy of the iliac artery lesion showed an intense myointimal hyperplasia. We performed standard hemostatic analysis and analyzed the activation markers of platelets and coagulation factors and the kinetics of thrombin generation in the patient and in normal control plasmas treated or not with reptilase. Occlusive arterial lesions were attributed to a disruptive hematoma penetrating the vascular lumen. Thrombin concentration after calcium addition increase markedly in the afibrinogenemic patient and in defibrinated normal plasma, as compared to untreated normal plasma. Thrombin-antithrombin complexes (T-AT) were markedly enhanced while F1 2 prothrombin fragments stayed in the normal range. These results suggested activation of coagulation and in vivo circulating thrombin. Thrombin activates the platelets that secrete growth factors for smooth muscle cells and generate the intimal hyperplasia. Recurrent hemorrhage within the vessel wall might induce injury and local thrombin generation. Thrombin not trapped by the clot is available for platelet activation and smooth muscle cell migration and proliferation. The absence of a protective fibrin cap on the intima might account for intima vulnerability and embolization. afibrinogenemia appears in this paradoxical situation as a vascular risk factor.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |
3/81. factor v Leiden and prothrombin G20210A in relation to arterial and/or vein rethrombosis: two cases.The factor v Leiden (FV Leiden) and prothrombin G20210A mutations, are the most common established genetic risk factors for deep vein thrombosis (DVT). However, the relationship between these mutations and arterial thrombotic syndromes (coronary heart disease, myocardial infarction, stroke) has not been established. Some studies have suggested a relationship between them, but other authors have considered it unlikely that these anomalies are a major risk factor for arterial thrombosis. From the clinical point of view, a question arises concerning the risk of repeated thrombosis in patients carrying one of these two mutations. The question is whether the recurrence is attributable to the mutations or to the presence of additional circumstantial risk factors. As the risk of repeated thrombosis varies considerably from one patient to another, decisions about long-term treatment require weighing the persistence of risk factors for vascular disease (venous and arterial), especially in selected cases such as young patients or patients with thrombosis of unusual localization.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |
4/81. The hemodialysis patient and hand amputation.The hemodialysis patient requires continued attention once an access surgery has been performed. These procedures lead to an anticipated physiological steal in the involved hand, but rarely lead to hand loss. When the patient has had previous peripheral vascular disease, known diabetes mellitus, multiple interventions on the same extremity, and the use of a synthetic graft, the incidence of digital or hand ischemia is significantly increased. This article represents 3 individuals who required hand amputation for severe ischemia. The pertinent clinical features in each individual will be explained and the literature reviewed for the factors promoting this complication and the all-autogenous access policies which may help to prevent hand ischemia.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |
5/81. Reversal of steal syndrome following creation of arteriovenous fistula by banding with a Gore-Tex cuff: a new technique.Steal syndrome, especially in elderly patients with peripheral vascular disease, is a serious complication following creation of an arteriovenous fistula (AVF) that, if neglected, can lead to amputation. The classic maneuver to deal with the steal syndrome is the ligation of the AVF and performance of another procedure to gain dialysis access. We describe a simple technique of effectively reversing the steal syndrome by banding the vein of the AVF with a ringed Gore-Tex cuff that salvages the AVF and allows its immediate use for dialysis.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |
6/81. Introduction to some common cutaneous foot conditions and their management.Problems that happen to the body through injury or disease can also happen to the owner's feet, and there are additional complications associated with the feet. Feet are a long way from the core, are in contact with an unclean environment (the ground), can be abused through poor-fitting footwear and are subjected to more general wear and tear than many other parts of the body. There are a large number of conditions affecting the feet, many associated with medical disorders such as diabetes, rheumatoid arthritis or peripheral vascular disease. The symptom of pain often triggers help being sought, but change in the appearance of the skin is a very important indicator of the state of superficial and deeper tissues. health-care professionals may be called upon to comment on these conditions and treat and/or refer accordingly, so a multidisciplinary approach is required. Clinical skill is required to identify the conditions which are treatable, or those which should be referred for treatment by someone in another specialism. This paper provides information for clinicians and interested others in the form of an introduction to some common cutaneous foot conditions through outline case examples and their treatment.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |
7/81. Clostridial enteritis necroticans versus secondary clostridial infection superimposed upon ischemic bowel disease.Clostridial enteritis necroticans, or pig-bel, as seen in papua new guinea, is a necrotizing, segmental gangrene of the small intestine occurring in members of a malnourished population, who become ill after consuming large quantities of pork contaminated with Type C. clostridium perfringens. We report a case of possible Clostridial enteritis necroticans with concomitant ischemic intestinal disease secondary to superior mesenteric arterial thrombosis occurring in a 53-year-old woman with a long history of diabetes mellitus, hypertension, and peripheral vascular disease. The differential diagnosis and the pathogenesis of C. perfringens enteritis necroticans are discussed.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |
8/81. Severe potential consequences of delayed diagnosis in patients with hip claudication.delayed diagnosis in patients with hip claudication can lead to severe consequences. We report on patients with ischaemic hip claudication which had primarily been attributed to coxarthrosis. One patient went through a variety of treatments including hip arthroplasty. The second patient had a life-threatening abdominal aortic aneurysm (AAA) which remained undiagnosed. Orthopaedic surgeons should maintain a high degree of suspicion for vascular disease. Moreover, we strongly advocate that all men over 60 years old who seek medical advice for whatever reason should be screened once for AAA by ultrasonography.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |
9/81. Angiographic improvement after rapid intermittent compression treatment [ArtAssist] for small vessel obstruction.A case is presented of a female ex-smoker who underwent bypass or exploration of all three below-knee arteries with failed results. Three separate arteriograms, performed at other academic institutions, demonstrated progressive, severe involvement of the pedal arteries. Therefore, the patient was prepared to undergo below-knee amputation surgery for uncontrollable rest pain and progressive necrosis of the forefoot; instead, the patient underwent 4 months of intermittent compression treatment. A fourth arteriogram, performed after 4 months of intermittent compression treatment (using rapid inflation/deflation and high-pressure cycle; ArtAssist demonstrated marked improvement of the posterior tibial artery runoff and development of more extensive collateral arteries in the calf. The patient's rest pain subsided and successful limb salvage was accomplished with a modified transmetatarsal amputation. This case could encourage other practitioners to repeat arteriography after compression treatments, which may redirect the treatment plan for selected patients with critical limb ischemia and nonreconstructable peripheral vascular disease.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |
10/81. Successful reversal of steal syndrome following creation of arteriovenous fistula by banding with a ringed Gore-Tex cuff: a new technique.Steal syndrome, especially in elderly patients with peripheral vascular disease, is a serious complication following creation of an arteriovenous fistula (AVF) that, if neglected, can lead to amputation. The classic maneuver to deal with the steal syndrome is ligating the AVF and performing another procedure to gain dialysis access. We describe a simple technique of effectively reversing the steal syndrome by banding the vein of the AVF with a ringed Gore-Tex cuff that salvages the AVF and allows its immediate use for dialysis.- - - - - - - - - - ranking = 1keywords = vascular disease (Clic here for more details about this article) |
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