Introducing the new Chronic Oedema Wet Leg Pathway

Reticence to apply compression therapy has been widely observed in clinical practice, compounded by an absence of evidenced-based pathways for application of prompt compression prior to measuring ankle brachial pressure index (ABPI). Importantly, delaying compression therapy for patients with chronic oedema and lymphorrhoea causes many avoidable complications. In 2017, Lymphoedema Network Wales (LNW) developed an evidenced-based pathway to improve the management of chronic oedema and wet legs (lymphorrhoea) for community nurses. During the past 4 years, the Chronic Oedema Wet Leg Pathway has been presented, published and used internationally, as well as being translated into different languages. It is commonly used in community nursing Teams as an evidenced-based document. However, like all documents and guidelines, when more evidence becomes available, the pathway needs updating. Therefore, this clinical focus article will present the new and enhanced Chronic Oedema Wet Leg Pathway, introducing a new level four compression section, which increases the layers of compression bandaging for patients with venous insufficiency or who are morbidly obese.

Surgical 5-year Outcomes of Extra-Anatomical Bypass for Middle Aortic Syndrome: A Case Series

Background Middle aortic syndrome is a rare disease. Several surgical treatments are available; however, the optimal treatment strategy and long-term outcomes remain unelucidated. We herein report the 5-year outcomes of six patients treated with extra-anatomical bypass surgery for middle aortic syndrome. Case presentations Between 2013 and 2016, six patients underwent extra-anatomical bypass for middle aortic syndrome at our institute: three had Takayasu’s arteritis, one had vessel vasculitis, and two had middle aortic hypoplastic syndrome of unknown origin. The patients included five women and one man, with a mean age of 59.7 years. Four patients had uncontrolled hypertension and were receiving antihypertensive medications. The mean ankle–brachial pressure index was .61. The three patients with Takayasu’s arteritis were hospitalized for congestive heart failure. These patients underwent bypass surgery from the descending aorta to the infrarenal abdominal aorta, and one also underwent concomitant heart surgery. The patient with microscopic polyangiitis underwent Y-grafting with an aortic aneurysmectomy. Subsequently, bypass surgery was performed from the descending aorta to the graft via the diaphragm. The two patients with unknown causes underwent bypass surgery from the proximal descending aorta to the distal descending thoracic aorta. There were no early or late deaths at the 5-year follow-up. We did not observe any changes in anastomotic site stenosis or new aneurysmal changes during the follow-up period. The number of antihypertensive medications was reduced in all cases, and critical symptoms, including headache, severe abdominal pain, claudication, and heart failure, improved in all patients. The ankle–brachial pressure index increased to 1.11 and did not change for five years. Renal function remained stable, and the brain natriuretic peptide level decreased from 302.8 to 74.5 pg/mL at follow-up. Conclusion Extra-anatomical bypass for middle aortic syndrome is safe and effective, and can help prevent renal failure, and relieve critical ischemic symptoms.

Association between modified ankle-brachial pressure index and indices of adiposity

Objectives: Obesity is one of the important risk factors for peripheral arterial disease (PAD). Ankle-brachial pressure index (ABPI) is a non-invasive test, which may be used for earlier detection of PAD. ABPI in healthy obese/overweight subjects has not been studied. In present study, we investigated correlation of adiposity indices with ABPI. We have also compared ABPI by three different methods in healthy obese/overweight subjects. Materials and Methods: Weight, height, body mass index (BMI), waist circumference, hip circumference (HC), waist height ratio, waist hip ratio, skin fold thickness, and body fat percentage were measured in 45 healthy overweight/obese males. Ankle and brachial pressures were measured by Doppler ultrasound based method. ABPI was calculated using high ankle pressure (ABPI-HIGH), mean ankle pressure (ABPI-MEAN), and low ankle pressure (ABPI-LOW) methods. Results: BMI and HC show positive significant correlation with ABPI-LOW (P = 0.028, P = 0.046, respectively). Significant difference was observed between ABPI-LOW and ABPI-HIGH (P = 0.003). ABPI-MEAN and ABPILOW were also significantly different (P < 0.001). Conclusion: There is a correlation of obesity indices with ABPI-LOW. ABPI-LOW methods could be more appropriate method and contrastingly HC may have direct correlation with PAD detection by ABPI in apparently healthy obese.

Retinal and choriocapillaris perfusion are associated with ankle-brachial-pressure-index and Fontaine stage in peripheral arterial disease

The purpose of this prospective case–control study was to assess whether parameters of retinal and choriocapillaris perfusion are altered in patients with peripheral arterial disease (PAD). Patients with PAD and healthy controls were imaged with swept-source optical coherence tomography angiography (OCT-A). Macula centered 3 × 3 mm OCT-A scans were acquired, binarized and perfusion was evaluated for vessel density (VD) and choriocapillaris non-perfused area. Clinical examination and non-invasive assessment included Fontaine staging, ankle-brachial-pressure-index (ABI) and vascular color-coded Doppler sonography. Fifty-two patients with PAD and 23 healthy controls were included. Superficial retinal VD was reduced in patients compared to controls (difference = − 0.013, p = 0.02), decreased with higher Fontaine stage (p = 0.01) and correlated with ABI (r = 0.42, p < 0.0001, 95% confidence interval [CI] 0.23–0.58). Choriocapillaris non-perfused area was larger in patients compared to controls (difference = 3.64%, p = 0.002, 95% CI 1.38–5.90%) and significantly correlated with ABI (r = − 0.22, p = 0.03, 95% CI − 0.40– − 0.03). Multivariate multiple regression analysis revealed a significant association of all OCT-A parameters with ABI and of deep retinal vessel density and choriocapillaris non-perfused area with Fontaine stage. In this first study of retinal and choroidal perfusion in patients with PAD we found both retinal and choroidal perfusion to be significantly impaired. OCT-A parameters could aid as indirect imaging biomarkers for non-invasive PAD staging and monitoring.

Prevalensi Penyakit Arteri Perifer Berdasarkan Nilai Ankle-Brachial Pressure Index di Universitas Mulawarman

Latar Belakang: Prevalensi penyakit arteri perifer (PAP) pada tahun 2015 di dunia diperkirakan lebih dari 200 juta orang. Penyakit ini terjadi pada <0,4 per 1000 orang pada usia 35-45 tahun dan 6 dari 1000 orang pada usia di atas 65 tahun. Namun prevalensi PAP dan faktor risiko yang mempengaruhi usia remaja sampai saat ini belum tergambarkan dengan jelas.Tujuan: Mengetahui prevalensi dan faktor risiko penyakit arteri perifer pada mahasiswa fakultas kedokteran Universitas Mulawarman.Metode: Penelitian ini melibatkan 141 responden dengan teknik pengambilan responden purposive sampling. PAP ditegakkan dengan interpretasi nilai ankle-brachial pressure index (ABPI). Nilai ABPI diukur menggunakan doppler vaskular dan sfigmomanometer, sedangkan faktor risiko diukur menggunakan kuesioner.Hasil: Penelitian ini mengidentifikasi 52,5% responden memiliki nilai ABPI normal, 44,7% mengalami PAP (ringan dan sedang) dan 2,8% kalsifikasi pembuluh darah. Faktor risiko PAP tidak memiliki hubungan yang bermakna dengan nilai ABPI/PAP dengan p value 0,730 (konsumsi makanan asin), 0,823 (konsumsi manis), 0,718 (minum kopi), 0,445 (merokok), dan 0,981 (aktivitas fisik).Kesimpulan: Kebiasaan mengkonsumsi makanan asin, makanan manis, minum kopi berlebih, dan kebiasaan merokok serta aktivitas fisik yang kurang dapat menurunkan nilai ABPI atau menjadi faktor risiko terjadinya penyakit arteri perifer.

A useful exercise test for detecting leg malperfusion due to aortic dissection

We herein report a case of leg malperfusion caused by dynamic obstruction after aortic dissection diagnosed by the exercise ankle brachial pressure index test that could not be diagnosed solely by examining the symptoms and investigations at rest. This case suggests that exercise can be a key factor in the diagnosis of this complication. Furthermore, blood pressure elevation can be an exacerbating factor in dynamic obstruction. We recommend conducting an aggressive evaluation of the symptoms and medical examinations not only at rest but also under stress.

Utility of Alternative Ankle Brachial Pressure Index for Screening Asymptomatic Peripheral Arterial Diseases in Patients with Acute Myocardial Infarction and Cerebrovascular Accident

BACKGROUND Peripheral arterial disease (PAD) is one of the macrovascular manifestations of systemic, diffuse atherosclerosis. Patients with acute myocardial infarction are at 3 - 5 times higher risk of developing associated PAD. Ankle Brachial Pressure Index (ABPI) is a simple, non-invasive test to diagnose peripheral arterial diseases in symptomatic cases. We wanted to assess the utility of an alternative formula for Ankle Brachial Pressure Index as a sensitive screening tool for asymptomatic peripheral arterial diseases in patients with acute myocardial infarction and cerebrovascular accident. METHODS This is a prospective observational study, recruiting eligible patients from medicine and cardiology outpatient department (OPD). Patients included were those with acute myocardial infarction (MI) or cerebrovascular accident (CVA). Sample size was calculated to be 257. ABPI was measured using a hand-held Doppler of 8 MHz and a standard sphygmomanometer. Statistical analysis was performed using SPSS software. RESULTS Alternate ABPI showed a mean value of 0.9 + / - 0.072. In the study population, 61.1 % were found to have abnormal ABPI i.e., less than 0.9, which is nearly two thirds of the population. Receiver operating characteristic curve (ROC) was plotted against ABPI for sensitivity and specificity for the co-morbidities considered in the study. It was found that the AUC (Area Under the Curve) was statistically significant for acute MI and acute CVA, with a fair positive correlation. CONCLUSIONS The alternative, ABPI is a good screening test for detecting asymptomatic PAD in patients with acute MI and CVA. However, further comparative studies are required to confirm the utility of the same in such patients, especially in a larger, varied population. KEY WORDS Ankle Brachial Pressure Index, Atherosclerosis, Peripheral Arterial Disease, Cardiovascular Diseases