Inelastic compression therapy - Is it superior to elastic compression therapies?

Inelastic versus elastic leg compression in chronic venous insufficiency – what are the effects on venous hemodynamics

In the venous disease of the lower limbs, compression therapy is considered as an important component of the treatment. There are many ways to deliver the compression therapy to the legs in the venous disease patients.  Compression therapy can treat venous stasis, venous hypertension, and venous edema. Different methods of compression therapy have been described periodically over the last 2,000 years. In addition to static compression, specialized compression pumps have been developed to treat resistant edema. A technique of massage called manual lymphatic drainage has emerged to treat primary and secondary lymphedema. Objectives of compression therapy are to reduce the swollen limb to minimum size, maintain that size, and allow the patient to participate in the care of his limb whenever possible. Reduction therapy is achieved by limb elevation, compression pumps as necessary, and compression wraps. Maintenance therapy largely consists of compression wraps or compression stockings. Nonelastic devices have found a place in treating severe lymphedema but it should be emphasized that periodic follow-up must be done during maintenance therapy so that adjunctive maintenance measures can be added as needed. In tropical countries under humid conditions people find it difficult to tolerate the compression therapies unlike those living in the cold countries. People (farmers) working in the wet fields refuse to wear the compression bandages. We need to need monitor the compression therapy measures at regular intervals and make sure that the people regularly apply them.

A brief history of compression

Descriptions of limb compression therapy are found in the Corpus Hippocraticum (450-350 BC). Because the Greeks believed that “all wounds, especially those of the lower limbs, contradict standing, sitting or walking,” they used compression to counter the adverse effects of gravity and upright posture. Guy de Chauliac, a French anatomist and surgeon, published the first mention of compression therapy for varicose veins in Chirurgica magna (1363), a leading reference textbook for almost four centuries. Giovanni Michele Savonarola (1440) formalized “conservative treatment” for varicose veins. His Practica describes how bandages should be started at the distal part of the limb and worked upward to the proximal portion. Savonarola’s successor at Padua University was Fabricio d’Aquapendente (1537-1619), who further refined these bandaging methods. The first description of laced stockings (made from dog leather) can be found in his De chirurgicis operationibus. (Contrary to popular belief, this is not the reason why “going barefoot” came to be known as “airing out your dogs”). William Harvey’s 17^th century description of the circulation of blood led to an understanding of the physiological rationale for limb compression. By the latter 18^th century, Johann Christian Anton Theden (1714-1797) was postulating that compression “reduces somewhat the flow of humours, stimulates the activity of the skin over the suffering areas and increases the returning flow of humours.”The use of sponges under a compression device (to apply additional pressure over specific areas) was introduced by E. Home and others (1797). The need for a bandage that could be applied by the patient led H.A. Martin in Boston to develop a clothless bandage made of pure rubber, which could be placed directly atop the skin and held in place by another bandage. Thomas Baynton advocated adhesive bandages and promoted their use after they became commercially available toward the end of the 19^th century. The zinc oxide paste dressing, introduced by P.G. Unna in 1885, is still in use today. Ready-to-use zinc oxide bandages came onto the market after the First World War (Varicosan, Glauco, Weicosana, others). Modern elastic stockings were born on October 26, 1948 when William Brown, of Middlesex, England, submitted a patent for compression hose.

The first compression pumps were introduced in 1902 when Hofmeister proposed a treatment for arm edema in which the limb was placed within a metal cylinder filled with mercury. In 1917, Hartel used an air-filled tube for the same purpose. Hammersfahr (1931) published his treatment of venous stasis using an air cushion that filled and emptied rhythmically. Karl Linser developed a massage boot that utilized an air-filled chamber in which the pressure varied as the subject walked.

Manual lymphatic drainage has been used to remove extremity edema for more than 50 years. The original technique used soft massage to stimulate lymphatic vessels and propel fluid through their channels. Because 20% or more of patients with chronic venous insufficiency also have a component of lymphedema, manual lymphatic drainage may have a role in a compression therapy program for chronic venous insufficiency.

Nonelastic devices. The Circaid® (see Fig) provides rigid nondistensible resistance to the limb. It can be applied over a compression stocking for additional compression.

Topical compression therapy provides a means to treat or prevent these adverse effects. Limb compression (1) alters the tissue pressure gradient, which reduces edema formation and increases edema resorption; (2) reduces the caliber of the veins and increases venous flow velocity; (3) reduces orthostatic reflux, residual volume, and ambulatory venous pressure (in part, by re-recruiting venous valves and reducing reflux in the perforating vessels); and (4) improves the effectiveness of the muscle pump.

Mayberry et al (1991) - In 16 patients with CVI – compression therapy affect was studied on – femoral, popliteal vein velocities (duplex scan), reflux and ambulatory venous pressures direct measurement. Although stocking produced substantial superficial vein, they produced only modest increases in the popliteal vein velocity and no significant improvement in deep venous hemodynamics. These authors analysed another 8 studies (previous) and said the differences in the findings were due to consistencies in the study designs.

R K Spence et al (1996 -JVS) found that inelastic compression (see fig Circaid) has a significant effect on deep venous hemodynamics by decreasing venous reflux and calf muscle pump function better than compression stockings. They concluded that initially the superficial reflux should be adequately treated with stockings. Those with extensive clinical symptoms caused by abnormal deep venous hemodynamics and primary calf muscle pump dysfunction may benefit more from the inelastic compression. 

Carotid intima media thickness (DCCT/EDIC) long term followup

The Diabetes Control and Complications Trial (DCCT) has documented the profound beneficial effects of intensive diabetes therapy (INT) compared with conventional therapy (CON) on the development and progression of microvascular and neuropathic complications during the DCCT, mediated by the separation of HbA_1c levels between the two treatment groups. In addition, the further separation of these outcomes during the Epidemiology of Diabetes Interventions and Complications (EDIC) study, despite the disappearance of the differences in HbA_1c seen in the DCCT (metabolic memory), has been described. The long-term benefits of INT versus CON are almost completely explained by the differences between the two groups in the mean level of HbA_1c during the mean of 6.5 years of treatment in the DCCT .

They assessed carotid IMT by ultrasonography at EDIC years 1, 6, and 12 . At year 1, the results were largely within the age-matched, nondiabetic range with no difference between the DCCT INT and CON groups. Carotid ultrasonography was again repeated during EDIC year 6. During the ∼5 year period between the two measurements, IMT increased within both groups, significantly more so in the former CON than INT group (Fig. 1). Ultrasonography was again conducted during year 12 (12). IMT increased even more in both groups, consistent with the recognized effects of aging. The magnitude of the increase between EDIC years 6 and 12 was slightly greater in the former INT than in the CON group, but the mean IMT remained significantly less at 12 years in the former INT group.

NETs and Deep vein thrombosis

Deep vein thrombosis (DVT) is a major health problem that requires improved prophylaxis and treatment.Inflammatory conditions such as infection, cancer, and autoimmune diseases are risk factors for DVT. We and othershave recently shown that extracellular DNA fibers produced in inflammation and known as neutrophil extracellulartraps (NETs) contribute to experimental DVT. NETs stimulate thrombus formation and coagulation and are abundant inthrombi in animal models of DVT. It appears that, in addition to fibrin and von Willebrand factor, NETs represent a third

thrombus scaffold. Here, we review how NETs stimulate thrombosis and discuss known and potential interactions ofNETs with endothelium, platelets, red blood cells, and coagulation factors and how NETs could influence thrombolysis.It was proposed that drugs that inhibit NET formation or facilitate NET degradation may prevent or treat DVT. 

Deep vein thrombosis (DVT) is a debilitating disease that may be complicated by pulmonary embolism (PE). Together DVT and PE are designated as venous thromboembolism. In the United States, venous thromboembolism develops in an estimated 900000 patients each year, and PE is responsible for ≈300000 deaths, which exceeds the mortality from myocardial infarction or stroke.DVT complications, in addition to PE, include post thrombotic syndrome caused by chronic venous stasis even in the absence of active thrombosis

NETs are produced to allow neutrophils to trap and disarm microbes in the extracellular environment. NETs are scaffolds of intact chromatin fibers with antimicrobial proteins, ideal to retain large quantities of microbes. Therefore, some pathogenic bacteria have evolved to express an extracellular deoxyribonuclease (DNase), which dismantles NETs and promotes virulence. Extracellular traps are formed in humans, animals, and even plants, indicating that NETs provide an evolutionary conserved protective mechanism. 

NETs formation is not restricted to neutrophils, and different cell types use different cellular mechanisms to release extracellular trap. One mechanism used by human neutrophils is NETosis. NETosis is a multistep cell death program . On activation, certain enzymes translocate from the granules to the nucleus. Histones are degraded by neutrophil elastase (NE) and citrullinated by peptidylarginine deiminase 4 to unwind chromatin. Further hallmarks are the breakdown of granular and nuclear membranes and cytolysis as the final step in NETosis.

Implications of NETs in Thrombolysis -To degrade and solubilize thrombi to restore blood flow, fibrin  and VWF as the main scaffolds need to be proteolytically fragmented by the proteases plasmin and a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13,  respectively. NETs are newly recognized third scaffolds that need to be undone during thrombolysis (Figure 1C). NETs were seen to colocalize with fibrin in clots 15 and with VWF in venous thrombi. In vitro, we could show that NETs provide a scaffold for blood clots that is resistant to tPA-induced thrombolysis. We incubated recalcified blood with neutrophils which were prestimulated to release NETs. As shown in  Figure 3, after filtration, blood clots appeared in control samples and tPA- or DNase-treated blood but not in blood treated with the combination of tPA and DNase. Immunostainings revealed that in the presence of tPA, blood clots lacked fibrin and were held together by a scaffold  of extracellular DNA (Figure 3B). DNase1 is the predominant nuclease in plasma. Interestingly, the plasminogen system cooperates with DNase1 during chromatin degradation. DNase1 has only limited activity to degrade chromatin because it preferentially degrades protein-free DNA. Plasminogen, activated by either tPA or urokinase-type plasminogen activator, degrades histones and therefore allows for degradation of DNA by DNase1. Monocytes/macrophages may also support the DNA degradation because their lysosomes contain DNase2, which is important for the removal of apoptotic cells (Figure 1C). NETs and fibrin degradation by plasmin and DNase could result in the simultaneous release of DNA and fibrin fragments.  In baboon DVT, plasma DNA increases with similar kinetics to the fibrin degradation product D-dimers. Recently, in collaboration with Thomas Wakefield’s group, we found increased levels of DNA in plasma from patients with DVT compared with healthy controls and symptomatic patients who did not have DVT. Here also, plasma DNA con-centrations correlated with D-dimers (unpublished data; Diaz and Fuchs, 2012). Therefore, it is plausible that circulating DNA may reflect the degradation of NETs within a thrombus.NETs may also promote thrombolysis. In vitro studies have shown that NE and cathepsin G can degrade fibrin, and these proteases are present on NETs and could enhance fibrinolysis in DVT. In addition, NETs may also recruit plasminogen from the plasma. Histone H2B can serve as a receptor for plasminogen on the surface of human monocytes/macrophages and perhaps could do so in NETs.

hepPTFE AVGs failed to improve patency or decrease secondary interventions compared to standard PTFE grafts used as Arteriovenous grafts for dialysis

Vascular occlusions in the lower limbs require a bypass operation. A conduit is needed for the bypass operation. Autogenous vein graft from the contralateral limb or ipsilateral limb is considered as an ideal conduit for the bypass operations. But it is not available or inadequate in 20-30% of the patients requiring bypass operation. Then one has to use the synthetic vascular graft in the absence of autogenous vein graft. The synthetic vascular grafts are modified over a period of time to improve the patency and reduce the recurrent thrombosis and also reduce the need for reinterventions. Porous dacron grafts need preclotting and that is not needed in the PTFE grafts. The kinking and rotation of the synthetic grafts in the long subcutaneous tunnels is avoided  by external support (rings/spirals). In a similar way there were many attempts to make the inner surface of the graft less thrombogenic and heparin bonding (coating) was one of them. These grafts have initially shown better results in the literature and they are available in the market. But there were not many papers to establish the indications and evaluating the long term results. Now these vascular grafts are also used for creating AV fistula for  patients requiring hemodialysis and known as arterio-venous grafts. The long term patency of the A-Vgrafts without re-interventions is a boon for the patients. It was hoped that the heparin bonding to the internal luminal surface of the Arterio-Venous grafts may prevent the thrombosis.

Recently a paper is published saying that Heparin Bonding Does Not Improve Patency of Polytetrafluoroethylene Arterio-Venous Grafts by Matthew TA et al (Feb 2013). A total of 223 patients had 265 grafts placed. Of these, 62 (23%) were hepPTFE grafts. The average age was 66 ± 15 years in the hepPTFE group and 59 ± 17 years in the non–heparin-bonded control group (PTFE; P < 0.01). Of the hepPTFE group, 39% were men, 81% were African American, 63% were diabetic, and 81% had a tunneled catheter at the time of access placement. Of the PTFE group, 35% were men, 85% were African American, 56% were diabetic, and 83% had a tunneled catheter. HepPTFE grafts failed to improve rates of primary, assisted primary, or secondary patency based on univariate analysis (hazard ratio [HR]: 1.37 [95% confidence interval {CI}: 0.99–1.88]; HR: 1.39 [95% CI: 0.98–1.96]; and HR: 1.20 [95% CI: 0.73–1.96], respectively). The number of secondary interventions was similar in the 2 groups (1.1 interventions per person-year of follow-up PTFE versus 1.4 hepPTFE; P = 0.13). A multivariable model including age, diabetes, peripheral artery disease, tobacco use, previous access placement, and tunneled catheter found that the HR for hepPTFE was not significantly different than PTFE in primary, assisted primary, or secondary patency (HR: 1.32 [95% CI: 0.91–1.90]; HR: 1.35 [95% CI: 0.91–1.99]; and HR: 1.15 [95% CI: 0.62–2.16], respectively.
This probably indicates that the intraluminal thrombosis of Arterio-Venous Grafts (AVGs) in the patients undergoing Dialysis is dependent on many other factors other than less thrombogenisity of the intraluminal surface of the grafts.

A 15-fold increase in rates of mortality due to cardiovascular disease and coronary heart disease among subjects with large-vessel peripheral arterial disease !!! do you believe?

Peripheral arterial disease (PAD) is a widespread vascular disorder that has been addressed for over a century and continues to affect a large portion of the modernized world. Both symptomatic and asymptomatic PAD affects 4.3% of the U.S. population aged ≥40 years of age1 and is recognized as a chronic atherosclerotic progression of lower-extremity arterial obstruction, which eventually leads to limb-threatening ischemia. PAD is functionally defined as an occlusive disease that generates a resting ankle–brachial index (ABI) of ≤0.90,2 although an ABI of between 0.9 and 1 is considered borderline and may introduce diagnostic subjectivity. PAD is strongly associated with terminal coronary artery disease for patients both with and without a significant cardiovascular history.3 As defined by a history of cardiovascular events or interventions (abdominal aortic aneurysms, transient ischemic attacks, stroke, carotid endarterectomy, history of angina, myocardial infarction, coronary angioplasty, and/or coronary artery bypass graft surgery), general cardiovascular disease has been associated with 70% of patients with PAD, rendering its diagnosis a significant indication for pan-vascular risk.4 Thus, the timely detection of PAD permits treatment of the diseased limb and preemptive management of cardiovascular risks.5 Preliminary PAD screenings have evolved into routine, noninvasive vascular laboratory studies, which reduce the risks, time, and costs associated with angiography. 

In a 10 years followup study published in Annals of vascular surgery in 1992 it was found that  - Twenty-one of the 34 men (61.8 percent) and 11 of the 33 women (33.3 percent) with large-vessel peripheral arterial disease died during follow-up, as compared with 31 of the 183 men (16.9 percent) and 26 of the 225 women (11.6 percent) without evidence of peripheral arterial disease. After multivariate adjustment for age, sex, and other risk factors for cardiovascular disease, the relative risk of dying among subjects with large-vessel peripheral arterial disease as compared with those with no evidence of such disease was 3.1 (95 percent confidence interval, 1.9 to 4.9) for deaths from all causes, 5.9 (95 percent confidence interval, 3.0 to 11.4) for all deaths from cardiovascular disease, and 6.6 (95 percent confidence interval, 2.9 to 14.9) for deaths from coronary heart disease. The relative risk of death from causes other than cardiovascular disease was not significantly increased among the subjects with large-vessel peripheral arterial disease. After the exclusion of subjects who had a history of cardiovascular disease at base line, the relative risks among those with large-vessel peripheral arterial disease remained significantly elevated. Additional analyses revealed a 15-fold increase in rates of mortality due to cardiovascular disease and coronary heart disease among subjects with large-vessel peripheral arterial disease that was both severe and symptomatic.

1. Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999–2000. Circulation. 2004;110:738–743
2. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45(Suppl. S):S5–67
3. Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326:381–386
4. Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286:1317–1324
5. Verhaeghe R. Prophylactic antiplatelet therapy in peripheral arterial disease. Drugs. 1991;42((Suppl. 5)):51–57

We should check the ABI in all patients at risk of peripheral arterial disease!

International ABI awareness as the next step in the PAD campaign

Coronary artery disease, cerebrovascular disease are well known in the society as the cause for heart attack (MI) and brain attack (stroke). Peripheral artery disease is the third most common manifestation of the atherosclerosis and one can lose lower limb if the critical ischemia is precipitated by other factors. The awareness of peripheral vascular disease is not adequate enough among the people in our society or general practioners to avoid complications and toe or limb loss in India and many other countries.

Peripheral artery disease (PAD) is common, underdiagnosed, and undertreated. Owing to the systemic nature of atherosclerosis, PAD patients are at risk for polyvascular disease. For example, 63% of patients with PAD have concomitant symptomatic cerebrovascular or coronary disease. Accordingly, PAD patients are at significantly increased risk for myocardial infarction, stroke, and vascular death over a 5-year period compared to age-matched cohorts.  

The ankle–brachial index (ABI) is the preferred initial test for PAD screening and diagnosis. It is relatively inexpensive, sensitive, and specific. Current guidelines provide clear recommendations on the indications for ABI testing. However, these guidelines may not have been fully implemented among practitioners.

In our practice we rarely see patients getting referred based on the ABI recorded in the clinics. The clinicians ask for Colour Doppler study (both legs costing Rs 2000 to 3000) and then send them with a report saying diffuse peripheral vascular disease in the diabetic and smoking population. Then we are doing the ankle brachial index in our clinic to classify degree of ischemia. One should practice checking the ankle brachial index routinely in patients with suspected peripheral arterial disease.

In a survey conducted in Australia, it was found that strikingly low 6% of GPs were aware of evidence-based guidelines on PAD screening, and only 5% were aware of guidelines on PAD diagnosis. The majority of GPs (58%) never perform ABIs. Most notably, 70% of the respondents choose arterial duplex (which is more costly and time-consuming) as the initial diagnostic tool in a patient with a history and physical exam consistent with PAD; younger GPs were more likely to choose the ABI. I think we are no better than the GPs in Australia in the evaluation of Peripheral vascular disease in the community.

The most common ‘moderate to major’ barriers to PAD screening and testing were (1) equipment availability, (2) time constraints, (3) lack of training and skills, and (4) staff availability. The time constraint barrier is not surprising, given that the time for an ABI could approach the 15-minute length of a typical primary care office visit. Other studies have also identified limited reimbursement and time as primary barriers to widespread use of the ABI in primary care practices.

I think, by increasing the awareness and improving staff ability more and more GPs will make an attempt to record the ABI in their practice and follow their patients for the CV events and extend better protection measures to avoid the amputations.

Surgical site infection in Diabetics- Is it related to preoperative HBA1c levels ?

We are all concerned about the surgical site infections in diabetic individuals. This is more important in patients undergoing surgery with implantable devices such as vascular surgery, orthopedic surgeries. It is probably better to correct the HBA1c prior to surgery in elective cases. Patients and their relatives should be informed and explained about the importance of metabolic control and correction of the HBA1c prior to the major elective operations. We prefer to correct the anemia before elective surgery in a similar manner it would be better to correct the metabolic problems.
In a recent paper published it was found that the surgical site infections were associated with high HBA1c. DM patients whose blood glucose levels were poorly controlled before surgery were at high risk for SSI. To prevent SSI in DM patients, we recommend lowering the HbA1c to <7 .="" font="">http://www.ncbi.nlm.nih.gov/pubmed/24368606  J Orthop Sci. 2013 Dec 25

What will happen to venous functions in 5 years, if iliofemoral deep vein thrombosis is treated with Anticoagulation only!

Akesson H et al (1990)examined 20 patients over period of 5 years who were treated for acute iliofemoral DVT with anticoagulation.

To determine the chronological changes of venous physiology following major thromboses, 20 patients were repeatedly examined for over 5 years after an acute ilio-femoral thrombosis which was treated with conventional anticoagulation. Radionuclide angiography showed that 70% of the patients had obstructive lesions of the iliac vein with only minor changes occurring from 6 months to 5 years. In spite of this, the plethysmographic maximum venous outflow increased from 31 to 45 ml/min/100 ml (P less than 0.001).
The foot volumetric reflux did not change with time and about half of the patients had abnormal values. Venous reflux assessed by the refill time of foot vein pressure, deteriorated with time (P less than 0.05), and at 5 years all but one patient had a refill time less than 20 s. The muscle pump function, examined by foot volumetry, was abnormally low in about half of the patients throughout the study.
The ambulatory foot vein pressure was constantly pathological (greater than 60 mmHg) in half of the patients and only two of 18 patients had normal values (less than 45 mmHg) at 5 years. Five patients with thromboses involving only the proximal veins had better physiological results than 15 patients with thromboses that extended to the peripheral veins. Three patients who developed venous claudication had iliac vein obstruction and an impaired venous outflow and three patients who developed venous ulcers had venous reflux and severe venous hypertension. Although venous outflow continuously improves following ilio-femoral thromboses, valvular competence and muscle pump function are constantly pathological, creating severe venous hypertension with a risk of post-thrombotic sequelae.
This study shows that -Obstruction can be over come after a period of time with recanalization and neovascularization.But the reflux is going to get worse with passage of time. People with venous reflux after 10 years will be showing the classical signs of venous hypertension.

Carotid artery intima media thickness (CIMT) is it a reliable marker of atherosclerosis?

In our county we do not measure the carotid artery intima media thickness in the routine clinical practice. But for the research trials this examination is done to know effect of drugs. This is a surrogate marker. There are doubts raised about the value of the CIMT measurement to know the CV risk. The CIMT may not give more information than that shown by traditional risk factors. A large number of prospective studies have demonstrated that carotid artery intima-medial wall thickening is predictive of major cardiovascular events, independently of traditional risk factors, with risk ratios ranging from 1.4 to 5.1 for coronary heart disease, and from 2.0 to 3.5 for stroke. Because of its established predictive value and its quantitative measurement with high precision and reproducibility rates, CIMT is also being employed as a surrogate endpoint in numerous clinical trials involving lipid-lowering or anti hypertensive drugs.
Simon A, Gariepy J, Chironi G, Megnien J, Levenson J. Intimamedia thickness: a new tool for diagnosis and treatment of cardiovascular risk. J Hypertens 2002;20:159—69.
Simon A, Megnien JL, Chironi G. The value of carotid intima media thickness for predicting cardiovascular risk. Arterioscler Thromb Vasc Biol 2010;30:182—5.
Lorenz MW, Markus HS, Bots ML, Rosvall M, Sitzer M. Prediction of clinical cardiovascular events with carotid intima-media thickness a systematic review and meta-analysis. Circulation 2007;115:459—67.
Den Ruijter HM, Peters SA, Anderson TJ, et al. Common carotid intima-media thickness measurements in cardiovascular risk prediction: a meta-analysis. JAMA 2012;308:796—803.

Carotid artery plaque may be a better predictive marker than CIMT. Indeed, when measured in the common carotid artery usually free from atherosclerotic plaque, CIMT is not a specific marker of the atherosclerotic process, but it reflects  medial hypertrophy, particularly as a consequence of hypertension or ageing. Accordingly, polled data from several longitudinal studies showed that the absolute risk of coronary
heart disease at 10 years associated with the presence of carotid plaque was 25% compared with 8% (low risk) in the absence of plaque, contrasting with an absolute risk of 11 to 15% (still intermediate risk) in subjects with CIMT > 95th percentile. However, the current recommendation to measure CIMT in order to reclassify intermediate-risk subjects  is not supported by its actual predictive value, which suffers established weakness beyond traditional risk factors compared with that of carotid plaque and coronary artery calcinosis.
http://ac.els-cdn.com/S1875213613000089/1-s2.0-S1875213613000089-main.pdf?_tid=dc099cf4-6bb5-11e3-93f6-00000aacb35d&acdnat=1387791637_b577dba96c2e307acb0ede59976abd00
In another study published in Lancet it was concluded that - The association between cIMT progression assessed from two ultrasound scans and cardiovascular risk in the general population remains unproven. No conclusion can be derived for the use of cIMT progression as a surrogate in clinical trials.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60441-3/abstract

Let us search and find new and better paths to reach, discover the ultimate truth and science behind management of Non-communicable diseases and facilitate the mankind to lead a better and healthy life. -Pinjala RK

Outcomes of Infra popliteal bypass in patients with gangrene of forefoot or toes!

J Vasc Surg. 1985 Sep;2(5):669-77.

Infrapopliteal bypass for established gangrene of the forefoot or toes.

Dalsing MC

Limb salvage by life-table analysis was 70% at 1 year, 60% at 3 years, and 28% at 5 years. The graft patency at 3 years was 65% for vein grafts and 30% for PTFE grafts.

In the entire series the operative mortality rate was 1.7%. Age, sex, hypertension, or diabetes mellitus did not influence the result of surgery. Similarly, failure of a previous femoro-popliteal or tibial graft did not reduce the likelihood of limb salvage. Graft patency, however, is prerequisite for limb salvage, and graft patency can be maintained by thrombectomy or repetitive bypass.

The present study suggests that limb salvage is possible in as many as two thirds of limbs with established gangrene. Although saphenous vein remains the graft material of choice, its absence should not preclude attempts at limb salvage. Repetitive grafting did not jeopardize patient safety but contributed significantly to extended limb survival.

From January 1977 through June 1983, 361 patients underwent infrapopliteal bypasses; 58 patients (59 limbs) had forefoot and/or toe gangrene. There were 33 men and 25 women (mean age 67.6 years), and 40 patients (69%) were diabetic. A total of 71 femorodistal bypass procedures were performed in these patients:A single bypass in 49, repeat procedure in eight, and multiple bypasses in two patients. Graft material was autogenous saphenous vein in 22 cases, polytetrafluoroethylene (PTFE) in 39 cases, and a composite graft in 10 procedures. After bypass 50 patients underwent limited toe or forefoot amputation with uncomplicated healing. 

There is always this question, should we do a bypass in a patient with forefoot or toe gangrene?  We should in a selected group of patients as this can be useful. 

Outcomes of Femoro-distal reconstruction in Diabetics and Non Diabetic patients -

Eur J Vasc Endovasc Surg. 2003 Mar;25(3):229-34.

Graft patency and clinical outcome of femorodistal arterial reconstruction in diabetic and non-diabetic patients: results of a multicentre comparative analysis.

Wölfle KD et al

Diabetes did not adversely affect graft function. For diabetics and non-diabetics primary cumulative patency rate at 1 year was found to be 66 and 56%, respectively (p=0.10) and a virtually identical limb salvage rate of 85 and 83% was achieved (p=0.76). 

With regard to healing of ischaemic foot ulcers a trend against diabetics was noted with a healing rate of 81% compared to 96% in non-diabetics at 1 year (p=0.067); gangrenous foot lesions could be equally remedied in 94% and in 87% among patients with and without diabetes (p=0.44). The survival rate of diabetics, however, was significantly lower with 78% at 1 year compared with 95% in non-diabetic patients (p=0.0004).

Infrainguinal bypass grafting can be safely done even in diabetics. Despite increased mortality in this group, liberal indication for reconstructive vascular surgery seems to be justified by favourable patency rates and clinical outcome in selected patients. I am not sure if the higher mortality is acceptable some of us!  The 17% higher mortality in diabetics compared to non diabetics after revascularisation at the end of 1 year may be too high!

Intermittent claudication

Intermittent claudication is a common condition affecting over 5% of the population over the age of 65 years.
Patients exhibit limited walking ability, but over recent years a number of studies have identified that claudication is also associated with significant impairments in overall physical function,1 including walking speed, lower limb strength, and balance. There is strong evidence that higher levels of daily activity in claudicants reduces functional decline and associated morbidity/mortality in the mid to long term. Furthermore, there is increasing evidence that claudicants have associated balance impairments that may predispose to an increased risk of falling and its associated physical and socio-economic consequences.

Percutaneous transluminal angioplasty results in improved physical function but not balance in patients with intermittent claudication - Risha Arun Gohil, et al
Objective: The aim of this study was to identify whether revascularization by percutaneous transluminal angioplasty (PTA) for patients with intermittent claudication improved measures of functional performance including balance.
Methods: A prospective observational study was performed at a single tertiary vascular center. Patients with symptomatic intermittent claudication (Rutherford grades 1-3) were recruited to the study. Participants were assessed at baseline (pre-PTA) and then, and 12 months post-PTA for markers of (1) lower limb ischemia (treadmill walking distances and ankle-brachial pressure index), (2) physical function (6-minute walk, Timed Up and Go, and chair stand time), (3) balance impairment using computerized dynamic posturography with the Sensory Organization Test, and (4) quality of life (VascuQoL and Short Form Health Survey [SF-36]).
Results: Forty-three participants underwent PTA. Over 12 months, a significant improvement was demonstrated in initial (P = .04) and maximum treadmill walking distance (P = .019). Physical functional ability improved across all outcome measures (P < .02), and some domains of both generic (P < .03) and disease-specific quality of life (P < .01). No significant improvement in balance was demonstrated by the Sensory Organization Test (P = .24).
Conclusions: Balance impairment is common in claudicants and does not improve with revascularization. Further research regarding effective treatment of balance impairment is required in this specific group of patients.

Journal of Vascular Surgery Volume 58, Issue 6, December 2013, Pages 1533–1539

Medial arterial calcification in the feet of diabetic patients

Diabetologia. 1993 Jul;36(7):615-21.

Medial arterial calcification in the feet of diabetic patients and matched non-diabetic control subjects.

Young MJ, Adams JE, Anderson GF, Boulton AJ, Cavanagh PR.

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Abstract

The prevalence and distribution of medial arterial calcification was assessed in the feet of four subject groups; 54 neuropathic diabetic patients with previous foot ulceration (U), median age 60.5 (50.5-67 interquartile range) years, duration of diabetes 19.5 (9.9-29.9) years; 40 neuropathic diabetic patients without a foot ulcer history (N), age 68 (62-73) years, duration of diabetes 14.0 (8.0-28.0) years; 43 non-neuropathic diabetic patients (NN), age 60.5 (52-68.5) years, duration of diabetes 14.0 (8.0-28.0) years and 50 non-diabetic control subjects, age 62.5 (53.7-70) years. A single radiologist graded medial arterial calcification as absent, mild or severe, at the ankle, hind-foot, mid-foot, metatarsals and toes on standardised plain lateral and antero-posterior foot radiographs taken by a single radiographer. Diabetes history, vibration perception threshold, ankle systolic pressure and serum creatinine were also assessed. 

Medial arterial calcification was significantly greater (total score 18 [3-31]) in neuropathic diabetic patients with previous ulceration (U vs N p < 0.01, U vs NN p < 0.001). 

Non-neuropathic diabetic patients did not have significantly higher arterial calcification scores than age-matched non-diabetic control subjects. 

Medial arterial calcification correlated with vibration perception threshold (r = 0.35), duration of diabetes (r = 0.32) and serum creatinine (r = 0.41), (all p < 0.01). 

Logistic regression models showed vibration perception and duration of diabetes to predict the probability of any calcification. Serum creatinine level was added to predict severe calcification.

Percutaneous transluminal angioplasty results in improved physical function but not balance in patients with intermittent claudication

Intermittent claudication is a common condition affecting over 5% of the population over the age of 65 years. Patients exhibit limited walking ability, but over recent years a number of studies have identified that claudication is also associated with significant impairments in overall physical function,including walking speed,  lower limb strength, and balance. There is strong evidence that higher levels of daily activity in claudicants reduces functional decline and associated morbidity/mortality in the mid to long term. Furthermore, there is increasing evidence that claudicants have associated balance impairments that may predispose to an increased risk of falling and its associated physical and socio-economic consequences.

Percutaneous transluminal angioplasty results in improved physical function but not balance in patients with intermittent claudication  Risha Arun Gohil, et al  Objective: The aim of this study was to identify whether revascularization by percutaneous transluminal angioplasty (PTA) for patients with intermittent claudication improved measures of functional performance including balance. Methods: A prospective observational study was performed at a single tertiary vascular center. Patients with symptomatic intermittent claudication (Rutherford grades 1-3) were recruited to the study. Participants were assessed at baseline (pre-PTA) and then, and 12 months post-PTA for markers of (1) lower limb ischemia (treadmill walking distances and ankle-brachial pressure index), (2) physical function (6-minute walk, Timed Up and Go, and chair stand time), (3) balance impairment using computerized dynamic posturography with the Sensory Organization Test, and (4) quality of life (VascuQoL and Short Form Health Survey [SF-36]). Results: Forty-three participants underwent PTA. Over 12 months, a significant improvement was demonstrated in initial (P = .04) and maximum treadmill walking distance (P = .019). Physical functional ability improved across all outcome measures (P < .02), and some domains of both generic (P < .03) and disease-specific quality of life (P < .01). No significant improvement in balance was demonstrated by the Sensory Organization Test (P = .24). Conclusions: Balance impairment is common in claudicants and does not improve with revascularization. Further research regarding effective treatment of balance impairment is required in this specific group of patients.

Sleep and Quality of Life

“Appetite and Sleep” are very important to enjoy the quality of life. The sleeping patterns are variable depending on the physical condition and different kinds of diseases.  

Recently a new study showed that poor sleep quality is strongly associated with mood disturbance and lower quality of life among people with extreme obesity. The study involved 270 patients with a mean body mass index (BMI) of 47.0 kg/m2 who were consecutively enrolled in a regional specialist weight management service. They had a mean age of 43 years. Sleep disturbance, daytime sleepiness, mood and quality of life were assessed using standardized questionnaires. The medical personnel working on night duties in busy centers are usually missing that necessary sleep. In a big hospital when there shortage of staff it is still worse as they may be doing continuous duties for 24 to 48 hours (weekend).

Some time back people were concerned about the decisions one would make in absence of sleep for saving the lives of critically ill patients. One can also see the mood changes in people deprived of adequate sleep which can affect the interpersonal relationships. The results of this recent study showed that 74.8 percent of participants were poor sleepers, and their mean self-reported sleep duration was only six hours and 20 minutes. Fifty-two percent of study subjects were anxious, and 43 percent were depressed. After controlling for age, sex, hypertension, diabetes, and obstructive sleep apnea, sleep quality and daytime sleepiness were significantly associated with mood disturbance and quality of life impairment.

"There was a clear association between the sleep problems such as short sleep duration and the psychological disorders and with quality of life," said Dr. G. Neil Thomas, lead supervisor, study methodology lead and reader in epidemiology at the Department of Public Health, Epidemiology and Biostatistics at the University of Birmingham in the United Kingdom. "These associations remained significant even after adjusting for a range of potential confounders." According to the authors, the potential role of sleep in the health and well-being of individuals with severe obesity is underappreciated. Although the cross-sectional design of the study did not allow for an examination of causality, the results suggest that the early detection of disturbed sleep could prevent the potential development and perpetuation of psychological problems among people with extreme obesity. "Despite the very high levels of problems in these patients, those involved with their care usually don't ask about sleep problems and often pay little heed to the psychological issues underlying the obesity," said Thomas. "The focus is often on treating the obesity and its consequences, such as diet and exercise interventions, rather than addressing its underlying cause, which may be psychological in nature, such as an unhappy marriage or job stress."

According to the Centers for Disease Control and Prevention, 35.7 percent of U.S. adults are obese with a BMI of 30 or higher. The CDC estimates that the annual medical cost of obesity in the U.S. was $147 billion in 2008 dollars. Obesity is a huge burden on the society in developed countries; it is soon to be seen in the other countries too. We are already seeing the advertisements on the road side by the people providing the bariatric surgery for the obese people.

In mammals and birds, sleep is divided into two broad types: rapid eye movement (REM sleep) and non-rapid eye movement (NREM or non-REM sleep). Each type has a distinct set of associated physiological and neurological features. The American Academy of Sleep Medicine (AASM) further divides NREM into three stages: N1, N2, and N3, the last of which is also called delta sleep or slow-wave sleep.

Academic Paper publications:

1. Masson's Hemangioma of Proximal Radial Artery - Tumour like vascular lesions are rare. Here we report a rare case of tumor like vascular lesion from the radial artery. A pulsatile swelling in the forearm is usually diagnosed as a case of Aneurysm, AV fistul... Ramakrishna Pinjala in Indian Journal of Surgery (2012)

2. Thrombophilia – How Far and How Much to Investigate?- Thrombohemorrhagic balance is maintained by complicated interactions between the coagulation and fibrinolytic system, platelets, and the vessel wall. Dr. Virchow provided approach for investigating and managin...

R. K. Pinjala, L. R. C. Reddy, R. P. Nihar, G. V. A. Praveen… in Indian Journal of Surgery (2012)      

3. Leiomyosarcoma of the Inferior Vena Cava:Segment II- R. Pinjala  Received 20 November 2012; accepted 24 April 2013. published online 10 June 2013. PII: S1533-3167(13)00019-8 doi :10.1016/j.ejvsextra. 2013.04.002 © 2013 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

4. Venous thromboembolism risk & prophylaxis in the acute hospital ... Ramakrishna Pinjala on behalf of all ENDORSE-India investigators*. Department of Vascular Surgery, Nizam's Institute of Medical Sciences, Hyderabad, India ...www.icmr.nic.in/ijmr/2012/july/0709.pdf - Cached - Similar

5. Retrospective evidence for clinical validity of expanded genetic model in warfarin dose optimization in a South Indian population Addepalli Pavani, Shaik Mohammad Naushad, Ramesh C Mishra, Amaresh Rao Malempati, Ramakrishna Pinjala, Takallapally Ramesh Kumar, Vijay Kumar Kutala  Pharmacogenomics, June 2012, Vol. 13, No. 8, Pages 869-878. 6. Optimization of warfarin dose by population-specific pharmacogenomic algorithm. Pavani A, Naushad SM, Rupasree Y, Kumar TR, Malempati AR, Pinjala RK, Mishra RC, Kutala VK. Source Department of Clinical Pharmacology and Therapeutics, Nizam's Institute of Medical Sciences, Hyderabad, India. Pharmacogenomics J. 2012 Aug;12(4):306-11. doi: 10.1038/tpj.2011.4. Epub 2011 Mar 1. Important functions During this year 2012-13: Elected President of the Vascular Society of India Received –  Fellowship from the Vascular society of India Promoted as Senior professor – in Nizam’s Institute of Medical Sciences Academic Associate Dean of the NIMS – Appointed Examiner for the National DNB-vascular surgery examination Examiner for MCh-Vascular surgery examination Theory Paper setting for the DNB and MCh vascular surgery examinations MCQs – for the entrance examinations for the vascular surgery MCh and DNB courses MCI – inspector  for examining the facilities at the centres to start the MCh vascular surgery. Attended the National and international conferences in India. Organizing chairman for the Annual meetings of Day care surgery, Diabetic foot society of India – Annual conferences in Hyderabad. Delivered Lectures on Deep vein thrombosis, Triple Combination therapy in Hypertension, Diabetic dysvascular foot, High dose statin therapy in the prevention of cardiovascular mortality, ischemia reperfusion syndrome, Diabetic foot infections, Newer anticoagulants.