Management of peripheral arterial disease in the elderly
Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich in Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
Table 30.7 states that the indications for lower extremity percutaneous transluminal angioplasty or bypass surgery are (1) incapacitating claudication in persons interfering with work or lifestyle; (2) limb salvage in persons with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, and/or infection or gangrene; and (3) vasculogenic impotence (160). Percutaneous transluminal angioplasty can be performed if there is a skilled vascular interventionalist and the arterial disease is localized to a vessel segment less than 10 cm in length (160). Compared to percutaneous transluminal angioplasty alone, stenting improves 3-year patency by 26% (161) After infrainguinal bypass surgery, oral anticoagulant therapy is preferable in persons with venous grafts, whereas aspirin is preferable in persons with nonvenous grafts (131).
Complications of hemodialysis access
Sachinder Singh Hans, Mark F. Conrad in Vascular and Endovascular Complications, 2021
The gold standard for the diagnosis of a stenosis in the hemodialysis circuit is a fistulogram. Additionally, a diagnostic fistulogram provides the ability to intervene if indicated. The basic indication for percutaneous transluminal angioplasty is stenosis > 50% or thrombosis of the AVF or graft. Primary patency within the first year after angioplasty is > 50%, while primary-assisted patency is 80–90% in the same time period. An example of a fistulogram revealing an outflow stenosis and subsequent angioplasty can be seen in Figures 29.1 and 29.2. A cutting balloon can be used as a second-line method, and stents and covered stents are reserved for the management of complications and central outflow stenosis.11 According to a study by Mohjuddin et al., fistula flow rate change was significantly better in native AVFs after fistuloplasty (percent flow increase 88.4%) than that in AVGs (percent flow increase 9.2%). Increase in fistula flow was greatest for valvular lesions (percent increase in flow: 42.6%), followed by lesions at the needling site (40.1%), peripheral outflow vein stenosis (29%), central outflow vein stenosis (25.9%), and at the anastomosis (19.9%).7
Thrombolytic Therapy
Hau C. Kwaan, Meyer M. Samama in Clinical Thrombosis, 2019
As discussed above, most arterial thrombi contain higher quantities of platelets than their venous counterpart. Since the platelets are rich in various inhibitors of fibrinolysis, including α2-antiplasmin and PAI-1, one would expect a greater resistance to lysis of an arterial thrombus. The thrombolytic approach to this form of thrombosis is modified in a number of ways. The use of “ultrahigh” dose SK has been advocated by Martin, who discusses this in Chapter 12. Recently, UK has been infused directly to the occlusion site via an angiographically-passed catheter.34,35 The tip of the catheter was advanced to within 2.0 cm of the proximal end of the thrombus and UK was infused at the rate of 4000 IU/min for 18 h, with encouraging results of 89% lysis. However, it is noteworthy that patients with advanced ischemic changes in the affected limbs should be excluded from this form of treatment, since severe revascularization complications may occur. Locally, compartment syndrome may occur requiring fasciotomy. The release of metabolic products from ischemic muscles into the circulation following revascularization may cause lactic acidosis, hypotension, hyperkalemia, acute tubular necrosis, congestive heart failure, adult respiratory distress syndrome, and disseminated intravascular coagulation. There are many potential advantages with thrombolytic therapy. A successful recanalization may allow the passage of a balloon catheter for transluminal angioplasty. The use of thrombolytic therapy is also associated with the advantage over thromboembolectomy in that the smaller branch vessels are rendered patent with lysis of the primary occluding thrombus.
Endovascular treatment for cerebral venous sinus thrombosis – a single center study
Published in British Journal of Neurosurgery, 2021
Thomas Hasseriis Andersen, Klaus Hansen, Thomas Truelsen, Mats Cronqvist, Trine Stavngaard, Marie Elisabeth Cortsen, Markus Holtmannspötter, Joan L Sunnleyg Højgaard, Jakob Stensballe, Karen Lise Welling, Henrik Gutte
Twenty-six patients received local thrombolysis (93%), 9 patients (32%) also underwent thrombectomy, whereas 2 patients (7%) were treated with thrombectomy only. In 5 patients aspiration was done either by a Penumbra clot aspiration system (Penumbra, CA, USA) or manual aspiration by hand using a large syringe (50cc). In the remaining 6 patients, mechanical thrombectomy was performed using a stent retriever. Two patients underwent percutaneous transluminal angioplasty. One patient (patient 13) underwent supplementary stenting of the thrombosed right transverse and sigmoid sinus with several carotid stents due to possible stenosis of the proximal sigmoid sinus. The median number of endovascular sessions were 2 (range 1–5; sessions where only digital subtraction angiography was performed were excluded), conducted one day apart in all but 4 patients. Complete recanalization of the affected sinus(es) assessed upon completion of the final endovascular session was achieved in 15 patients (54%), partial restoration in 11 patients (39%) and no restoration in 2 patients (7%).
Comparing treatment options for large vessel vasculitis
Published in Expert Review of Clinical Immunology, 2022
Federica Macaluso, Chiara Marvisi, Paola Castrignanò, Nicolò Pipitone, Carlo Salvarani
However, the evidence for biological agents in TAK is very limited and mostly derived from uncontrolled observations. In refractory cases, we prefer to use TNFi over TCZ because of the more robust evidence in their favor. Surgical procedures are needed in cases of cerebrovascular disease due to cervical vessel stenosis, coronary artery disease, moderate-to-severe aortic regurgitation, severe coarctation of the aorta, renovascular hypertension, limb claudication, or progressive aneurysm enlargement with risk of rupture or dissection. Bypass graft surgeries are associated with a better long-term outcome. Percutaneous transluminal angioplasty provides better results for short lesions than conventional stents. Surgical procedures should be performed whenever possible when the disease is adequately controlled by medications. A multidisciplinary approach is required to best manage large vessel vasculitis.
A fully coupled framework for in silico investigation of in-stent restenosis
Published in Computer Methods in Biomechanics and Biomedical Engineering, 2019
Shibo Li, Long Lei, Ying Hu, Yanfang Zhang, Shijia Zhao, Jianwei Zhang
Cardiovascular diseases, killing more than 17 million people yearly (WHO 2017), are the leading cause of death worldwide. Vascular diseases, such as atherosclerosis, may lead to stenosis or complete occlusion of the artery, which will result in life-threatening illnesses including stroke, myocardial infarction and pulmonary embolism. Currently, percutaneous transluminal angioplasty (PTA) is a most effective treatment for vascular stenosis. However, restenosis after PTA procedure has become a major limitation to the long-term benefit of the therapy. Although the drug eluting stent (DES) can extend the period of vessel patency comparing with bare metal stent (BMS), the fundamental issue remains due to its mechanical inheritance from BMS and the long-term biocompatibility requires further study (Martin and Boyle 2011) as well. In this context, further investigation is required to understand the biomechanical and mechanobiological mechanisms of the pathophysiological process, and meanwhile the comprehension to this problem can lead to better designs of the vascular intervention devices.
Related Knowledge Centers
- Balloon Catheter
- Stenosis
- Vascular Surgery
- Blood Vessel
- Atherosclerosis
- Minimally Invasive Procedure
- Medical Procedure
- Stent
- Percutaneous
- Coronary Arteries