Digital Subtraction Angiography Prior to an Amputation for Critical Limb Ischemia (CLI): An Expert Recommendation Statement From the CLI Global Society to Optimize Limb Salvage.

Despite recent guideline updates on peripheral artery disease (PAD) and critical limb ischemia (CLI) treatment, the optimal treatment for CLI is still being debated. As a result, care is inconsistent, with many CLI patients undergoing an amputation prior to what many consider to be mandatory: consultation with an interdisciplinary specialty care team and a comprehensive imaging assessment. More importantly, quality imaging is critical in CLI patients with below-the-knee disease.

Multidisciplinary Care for Critical Limb Ischemia: Current Gaps and Opportunities for Improvement.

Critical limb ischemia (CLI), defined as ischemic rest pain or nonhealing ulceration due to arterial insufficiency, represents the most severe and limb-threatening manifestation of peripheral artery disease. A major challenge in the optimal treatment of CLI is that multiple specialties participate in the care of this complex patient population. As a result, the care of patients with CLI is often fragmented, and multidisciplinary societal guidelines have not focused specifically on the care of patients with CLI.

Predictive value of high sensitivity C-reactive protein in the diagnosis and outcomes of acute aortic syndromes.

Objective: The purpose of this study was to determine whether high-sensitivity C-reactive protein (hsCRP) levels differ among patients with acute aortic syndromes (AAS) and if hsCRP could predict their long-term outcomes.

Design: Retrospective observational study.

Setting: Cleveland Clinic Hospital, Cleveland, Ohio.

Association of angiographic perfusion score following percutaneous coronary intervention for ST-elevation myocardial infarction with left ventricular remodeling at 6 weeks in GRACIA-2.

Unlabelled: Higher angiographic perfusion score (APS) following percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) has been shown to be associated with improved clinical outcomes. The association between APS after STEMI and left ventricular remodeling as assessed by volumetric parameters derived from left ventriculography has not been assessed.

Methods: The APS (the arithmetic sum of the TIMI Flow Grade (TFG) and TIMI Myocardial Perfusion grade (TMPG) before and after percutaneous coronary intervention (PCI), range of 0-12) was assessed in 168 patients from the GRACIA-2 trial.

Pernio (chilblains).

Pernio is a vasospastic disorder that affects unprotected skin regions of individuals exposed to nonfreezing, damp cold. It may be idiopathic or associated with other systemic diseases, particularly cryopathies and lupus erythematosus. Acute pernio manifests several hours following exposure, whereas chronic pernio may persist even after the cold season has long ended.

Outpatient management of stable acute pulmonary embolism: proposed accelerated pathway for risk stratification.

Pulmonary embolism (PE) is a major health problem and a cause of worldwide morbidity and mortality. The current standard therapy for acute PE encourages admitting patients to the hospital for administration of parenteral anticoagulation therapy as a bridge to oral vitamin K antagonists. Prognostic models that identify patients with stable (nonmassive) acute PE (SPE) who are at low risk for adverse outcome have recently been reported.

Peroxisome proliferator-activated receptor gamma agonists for the Prevention of Adverse events following percutaneous coronary Revascularization--results of the PPAR study.

Background: Patients with metabolic syndrome are at increased risk for cardiovascular complications. We sought to determine whether peroxisome proliferator-activated receptor gamma agonists had any beneficial effect on patients with metabolic syndrome undergoing percutaneous coronary intervention (PCI).

Methods: A total of 200 patients with metabolic syndrome undergoing PCI were randomized to rosiglitazone or placebo and followed for 1 year.

Contemporary management of peripheral arterial disease: III. Endovascular and surgical management.

Traditional indications for invasive treatment in patients with peripheral arterial disease (PAD) have been salvage of a threatened limb or improvement of functional capacity in cases of disabling intermittent claudication, but advances in interventional therapy may be lowering the threshold for these therapies. Percutaneous transluminal angioplasty (PTA), with or without stent placement, is the most common endovascular intervention in patients with occlusive lower extremity PAD. In general, PTA is best suited to cases of short-segment stenosis or large-bore vessels, whereas surgery is best applied to multilevel occlusions involving smaller and more distant vessels.

Heparin-induced thrombocytopenia in the critical care setting: diagnosis and management.

Background: Thrombocytopenia is a common occurrence in critical illness, reported in up to 41% of patients. Systematic evaluation of thrombocytopenia in critical care is essential to accurate identification and management of the cause. Although sepsis and hemodilution are more common etiologies of thrombocytopenia in critical illness, heparin-induced thrombocytopenia (HIT) is one potential etiology that warrants consideration.

Peripheral arterial disease: recognition and medical management.

Peripheral arterial disease (PAD) is common but has a variable presentation and is often unrecognized and undertreated. Patients with PAD have an increased risk of cardiovascular events and death. The ankle-brachial index is a quick, reliable diagnostic tool that also helps assess disease severity and prognosis.

Should we screen for abdominal aortic aneurysms?

Ultrasonography can screen for abdominal aortic aneurysms (AAAs) safely, cheaply, and accurately. Once detected, an AAA can be monitored and repaired before it is likely to rupture. The US Preventive Services Task Force recently recommended a one-time screening for AAAs by ultrasonography for men age 65 to 75 years who have ever smoked.

Managing abdominal aortic aneurysms: treat the aneurysm and the risk factors.

Abdominal aortic aneurysms (AAAs) are not only a danger in themselves, they also signify underlying vascular disease that warrants intensive cardiovascular risk reduction, especially smoking cessation. Aneurysmal size and the patient's fitness for surgery are the main determinants of timing and method of elective repair. The choice of open surgery vs endovascular repair depends on the patient's condition, preference, and life expectancy, and the surgeon's experience.

Heparin-induced thrombocytopenia: principles for early recognition and management.

Heparin-induced thrombocytopenia (HIT) is a potentially devastating complication of therapy with either unfractionated or low-molecular-weight heparin. Thrombocytopenia is no longer essential for the diagnosis of HIT, since a 50% drop in the platelet count may be a more specific indicator. Once HIT is clinically suspected, heparin should be stopped immediately and direct thrombin inhibitor therapy started; waiting for laboratory confirmation may be catastrophic.

Patients with acute pulmonary embolism should have an echocardiogram to guide treatment decisions.

A 62-year-old man with a past medical history notable for hypertension, osteoarthritis, and calf deep vein thrombosis at age 55 following a total hip arthroplasty presents to the emergency department with acute-onset dyspnea and right-sided pleuritic chest pains. His medications consist of a calcium channel blocker and a COX-2 inhibitor. Pretest clinical suspicion for pulmonary embolism (PE) is high.