The phenomenon of vasomotion, consisting in periodic oscillations of blood vessels walls is particularly important at the scale of small vessels and exhibits different features in arterioles (in which flow is mainly driven by the hydraulic pressure gradient) and in venules provided with valves preventing back flow and helping centripetal hematic propulsion. Here we formulate a model for both situations, based on approximations of the flow equations implied by the smallness of the radius-to-length ratio. For venules we postulate the presence of an inlet and an outlet valve and we show that the model reproduces the periodic pressure pulses that have been detected in the experimental literature devoted to venules of the batwing.
Purpura Fulminans is a severe disorder of acute onset with high morbidity and mortality. Purpura fulminans (PF) is a hematological emergency in which there is skin necrosis and disseminated intravascular coagulation. This may progress rapidly to multi-organ failure caused by thrombotic occlusion of small and medium-sized blood vessels. PF may complicate severe sepsis. It most often occurs with sudden appearance of symmetrical, tender, ecchymotic skin lesions usually involving the lower extremities. Early recognition and early therapy with appropriate antibiotics and heparin is known to limit both morbidity and mortality. This article reports a case of Purpura Fulminans presented with DIC after hemorrhagic shock of postpartum hemorrhage.
Atherosclerosis is a leading cause of mortality and morbidity in the western world. It is no longer a disease attributed mainly to the high lipid content of the body but has come to be regarded as a chronic inflammatory disease with an autoimmune component. Studies which explore the interactions between molecular and cellular elements generally focus on pathophysiologic aspect of atherosclerosis. The focus has now shifted to the novel risk factors and the genetic predisposition which has further broadened the pathogenetic mechanisms. Hence, It's high time to understand these processes in depth so that new markers and treatments which target mechanisms specially inflammation which is now the most exact cause of atherosclerosis. Moreover, the diagnosis and management is the guiding element in the understanding, progression of chronic diseases like atherosclerosis. Therefore, targeting and understanding of biochemical pathways would help in more accurate diagnosis and management of disease. Additionally, the use of antihyperlipidemic and anti-inflammatory drugs for the treatment of atherosclerosis was only possibility but it had average results. Henceforth, delving into newer areas or novel drug targets like endoglin receptor, PPARα, squalene synthase, thyroid hormone analogues, scavenger receptors, Leucotriene receptors, calcium signaling, Pentraxin, nitric oxide, heat shock proteins, Liver X Receptors, shear stress pathway, CD14, endotoxin signaling, and nuclear factor kappa B give better treatment possibilities to control the process of atherosclerosis. Therefore, the review briefly focuses on molecular mechanisms involved in the evolution of the atherosclerotic plaque and different novel targets that act at the starting stage of the plaque form to the thrombus formation in the atherosclerosis that may pave the way for selecting optimal therapies and preventing plaque complications.
Abstract Introduction Fertility preserving surgery is rarely performed in placenta accreta and atonic thinned out lower uterine segment is frequently encountered. Aim To evaluate our new method of uterine conservation in abnormal placentation and oozing from the lower uterine segment. Methods Multiple interrupted uterine plicating transverse compression sutures with combined multiple level uterine artery ligation were performed over 24 cases. Results Six cases were excluded for hemodynamic instability and placenta percreta. It was sucessful in all cases of thinned out lower segment and placenta previa but failed in two cases of placenta accreta. Conclusion Conservative management for atonic lower uterine segment and abnormal placentation through modified transverse B-lynch suture can be performed with high success and conserving female fertility.
Autologous veins are the conduit of choice when performing an infra-inguinal arterial bypass procedure. However these grafts are at risk of failure. This is multifactorial in nature and relates to patient factors, factors relating to the procedure as well as adaptive processes which occur after the formation of an infrainguinal bypass graft. Duplex ultrasound assessment of haemodynamic findings within the graft is the most accurate method of identifying vein graft stenosis and identifying grafts which are at risk of failure. Duplex ultrasound examination findings together with clinical factors can be used to individualise vein graft surveillance. This review examines the steps involved in a successful vein graft surveillance program, how to optimise the cost utility of vein graft surveillance by identifying the grafts which are at highest risk of failure and how there has been a paradigm shift away from surgical revision and towards endovascular revision of failing infrainguinal grafts.
Placenta percreta, is a rare pregnancy disorder in which the placenta penetrates the uterine myometrium and can invade the surrounding organs. It is a potentially life-threatening condition with severe maternal morbidity and mortality. Both sonography and MRI are used for prenatal diagnosis of placenta accreta. Prenatal diagnosis allows management of these patients in specialized tertiary centers, where a multidisciplinary approach will improve the outcome. A team of anesthesiologist, obstetrician, urologist, neonatologist, and blood bank officer is needed for successful management of these patients. Management and complications of placenta percreta in rare blood group. We present the case of a young age multigravida with placenta percreta and blood group 0 negative. She was managed by cesarean hysterectomy after bilateral internal iliac artery ligation before proceeding with placenta removal that was not recommended but aiming for excision and conservative surgical treatment with iatrogenic bladder injury and ureteral ligation that was not diagnosed intraoperative. We encountered a fullness in the retro-peritoneum that was not progressing so we considered it as hematoma but was revealed later as acute ureteric dilation from ligation. Due to poor availability of blood, she recieved limited amount. After 10 hours, she was mild hemodynamically unstable with right hydronephrosis and abdominal collection on ultrasound. She was reoperated with ureter caherterization and evacuation of hematoma. The patient was discharged 10 days after in good condition. A decision between radical and conservative strategies for placenta accreta must be made based on the degree of placental infiltration and other variables: the patient's hemodynamic status and her desire to remain fertile. In our opinion, cesarean hysterectomy remains the best therapeutic option to treat placenta percreta. Radical surgery should be done for poor availability of blood especially in rare blood types in other types of placenta accreta. Fullness in the retroperitoneal space should not be ligated except after excluding ureter dilatation and confirming hematoma by aspiration and disscetion. Megaureter may be gestational or pathological from ureteric ligation that is differentiated by hydronephrosis. Internal iliac artery ligation followed by cesarean hysterectomy with no trial of removal of placenta should be done to limit blood loss in placenta percreta. Fullness of bladder after repair should be washed as may be blood clot retention from bleeding. Megaureter could be presented intraoperative within minutes of ligation of the ureter and after hours by asymmetry between both kidneys regarding hydronephrosis. Bladder repair can be done by gynecologist but ureter ligation is better to be done by a urologist. Ureter identification should be considered before hysterectomy by visual assessment or dissection or proceeding with hysterectomy very close to cervix especially in total hysterectomy.
Cutaneous small vessel vasculitis (CSVV) are a spectrum of conditions characterized by an angiocentric inflammation mainly limited to the post-capillary venules of the skin. Neutrophils are the predominant cellular effectors of the inflammatory infiltration and destruction of the blood vessels. The most common clinical presentation is palpable purpura of the lower half of the legs but type, site and calibre of the involved vessel district influence the localization and severity of the clinical features that may include urticarial, bullous, nodular and necrotic-ulcerative lesions. CSVV are idiopathic in 50% of cases and associated with drug intake, infections, connective tissue diseases or malignancies. The histological confirm of the diagnosis is mandatory and a laboratory investigation protocol is useful to discriminate skin-limited forms from extracutaneous visceral involvement. Treatment is strictly dependent on the clinical aspects and potential chronicity. First line drugs are colchicine and dapsone in combination with general measures such as leg elevation, warming and rest, but in case of recurrences, systemic involvement or coexistence of associated diseases, immunosuppressive agents may be necessary.
Abnormal uterine bleeding after abortion or delivery requires special management. Sonography with clinical and laboratory findings are important to narrow the differential diagnoses. Presence of increased uterine vascularity and arteriovenous shunting can be detected in retained trophoblastic tissue, gestational trophoblastic disease, and placental polyps and uterine vascular malformation are mainly related to failure of detection of associated pathology in the uterus on ultrasound. Here we are describing to both as a same entity for simplicity. We present two cases of placental polyp with uterine vascular malformation, one case after abortion and the other case after vaginal delivery. The first case was multiparous female complaining of abnormal uterine bleeding three month after delivery. Ultrasound revealed diffuse uterine vascularity with echogenic vascular mass with blood flow velocity less than 40 cm/s that was evacuated and packed using hysteroscopy. The second case was also multiparus female complaining of abnormal uterine bleeding two months after abortion. Ultrasound revealed abnormal vascularity from perimetrium to the endmometrial mass. Hysteroscopic removal of the mass was done. Both patients were discharged after two days with menses resumed regularly afterwards. Uterine vascular malformations may be associated with heavy bleeding. They should be suspected on ultrasound with anechoic structures with positive Doppler signal. Dilatation and curettage is therapeutic for evacuation of placental polyps but can induce massive, life-threatening bleeding in cases with uterine arteriovenous shunting or malfomration (AVM), thus it should be done with caution in endometrial pathology with high velocity flow more than 40 cm/s as infection and adhesions are associated. Treatment of uterine AVM varies from medical management (hormonal therapy), minimally invasive uterine artery embolization to more definitive surgical hysterectomy, depending upon age of the patient, size, site of the lesion, and the desire to retain future fertility.
Raynaud's phenomenon is a common clinical disorder characterized by recurrent vasospasm episodes of digital arteries, arterioles, pre-capillary and post-capillary venules triggered by exposure to cold or emotional stress. RP can be classified as primary (idiopathic), or secondary to several diseases or conditions. The pathogenesis of RP is still not entirely clear or understood, but recent insights into the pathogenic mechanisms underlying Raynaud's phenomenon include vascular, neuronal and intravascular abnormalities which may identify crucial key points and potential targets for therapeutic intervention.
Attaining value captures the essence of economic activity organizations. Since inception of the concept, value chains have enhanced value creation in the physical world and resulted in new business opportunities in the virtual domain. Healthcare requires transformational change, in order to achieve the best outcomes. Value based healthcare is an adaptation of structures and processes which are designed to capture value in delivery of healthcare services.
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Buerger's disease (BD) is a peripheral vascular disease, the etiology of which was largely unknown until recently. Currently, various studies demonstrated the involvement of heavy metals in tobacco and other source as one of the causative factors. Heavy metals induce vascular dysfunction by inducing high oxidative stress, reducing the activities of endothelial nitric oxide synthase and enhancing the phosphorylation of myosin light chain kinases. Targeting and modulating these pathological mechanisms may provide novel pharmacological intervention to halt the progression of the BD. Hence, we hypothesized that chelating agents and antioxidants alone or combination therapy can help manage BD.
Post-thrombotic syndrome (PTS) is the most frequent chronic complication of acute deep vein thrombosis (DVT). However, gaps in our current understanding of the risk factors, diagnostic criteria, preventive strategies, and even treatment modalities for PTS prevent clinicians from employing measures that could reduce the occurrence of this disorder and the associated morbidity. This review provides an overview of the important elements of PTS, including recent multifaceted aspects related to its definition, pathophysiology, risk factors, prevention and management.
The Vasculab manoeuvre (VA) is a dynamic manoeuvre, specifically designed to study the physio-pathology of the venous calf muscle pump (CMP). It could be defined a simulated “in situ” step and adopts a simplified scheme of the walking step. The patient rolls forward on the leading foot, standing on the toes of both feet (systole, S) and can remain in this position to perform a sustained systole (SS) or can relax, shifting the weight on the other side (diastole, D). VA observations require a training period, while the patient must be provided a set of simple instructions, in order to get the knee extension and the spontaneous rolling on the foot plant. BMode ultrasound shows that in all examined cases MGVs are compressible in systole. A set of CMP specific measurements can be performed, like the refilling time and the stroke volume. VA is the only manoeuver to perform an ultrasound venous investigation in movement. In diastole the refill occurs by capillary inflow (vis a tergo) while reflux comes from incompetent veins. MGVs are taken as a model for the CMP, while the endo-venous compartment of the calf is used as a volumetric model of the leg. VA is a simply executable manoeuvre, which however hides a complex physiopathology, providing the estimation of the CMP parameters. In addition, VA can be used also in several types of plethysmography.
A commitment to continuously improve the quality of services provided lies at the heart of clinical practice in the 21st century. Vascular surgery has been going through significant changes through the introduction of new technologies and expanding evidence-base for timing and efficacy of vascular surgical interventions. Consequently, there has been a necessity to improve quality, safety, effectiveness and cost efficiency of systems of care which deliver vascular surgical services. This review discusses the theories relevant to quality improvement in healthcare and how they have been used in vascular surgery to improve outcomes and quality of care following vascular intervention.
Background Abnormal placental invasion has increased with persistent rise in cesarean delivery. Management depends on accurate diagnosis, and delivery should be planned at an institution with appropriate expertise and resources. Hemorrhage in pregnancy is the leading cause of maternal mortality in developing countries. Internal iliac artery ligation is one of the lifesaving procedures in intractable pelvic hemorrhage. The vascular malformations involving the abdominal aorta, common iliac artery and its branches are very rare.Case We present a case of placenta accreta which is a major risk for peripartum deaths. In this case, we tried to explain our conservative surgical approach in the form of cervico-isthmical transverse opposition suture with bilateral internal iliac artery ligation. Normally, the abdominal aorta bifurcates into the right and left common iliac arteries anterolateral to the fourth lumbar vertebra. In the present case, there was bilateral absence of common iliac arteries which are the terminal branches of the abdominal aorta. Internal iliac artery was extremely long and equal size to external one. The reason for the absence of common iliac artery may be attributed to the disappearance of the initial segment of the umbilical artery.Conclusion Cesarean section and placenta previa are significant risk factors for placenta accreta which is associated with high fetomaternal morbidity and mortality. In order to avoid postpartum hemorrhage and fertility loosing hysterectomy, our approach which consists of bilateral hypogastric arterial ligation and transverse compression sutures in the lower uterine segment can be applied successfully. Proper identification of anatomical variations in pelvic vasculature is essential for surgical and radiological interventions to prevent complications. This article aims at sharing author's experience about the anatomical variation of the artery especially long ones as in absent common iliac artery or even a high bifurcation.
Superficial venous disease (SVD) is a common condition in the Western world, with recognized, negative effects on mood and quality of life (QoL) in those affected. Numerous tools exist to assess QoL in patients with SVD. The aim of this article is to review the literature on the role of QoL assessment tools in this disease group, describing the most commonly used instruments and their relevance, assessing the relationship between clinical and functional assessment tools, delineating the correlation among physician and patient reports and discussing the importance of translation.
Varicose vein disease is common and has an adverse effect on patients. Treatment of the condition has been demonstrated to improve patients' physical well-being and quality of life. Surgical treatment has for a long time been the ‘gold standard’ method until the launch of endovenous thermal ablation towards end of the twentieth century. Indeed, being less invasive and offering the possibility of day-case local anaesthetic procedures, they have gradually become the mainstay of contemporary varicose vein treatment. Vein ablation using steam and microwave are new additions to thermal methods, but there is currently insufficient evidence as to their effectiveness and place in the management of varicose veins. The superiority of thermal ablation is now being challenged by endovenous non-thermal methods. Foam sclerotherapy, until recently the only endovenous non-thermal technique available, has been joined by mechanochemical ablation and cyanoacrylate glue as viable alternatives to thermal ablation. It is believed that these new non-thermal methods will be able to offer additional benefits to patients. This review of thermal and non-thermal ablation techniques assesses their respective merit in the management of varicose veins.
Arterial pseudoaneurysms (PSAs) following orthopedic and traumatologic surgery are rare and most publications on this subject are case reports. No update based on robust data has been published previously. The management of this pathology is not codified. We wanted to summarize the current knowledge on diagnostic and therapeutic features of these iatrogenic vascular injuries. Medline and EMBASE were queried for publications using the descriptors «artery pseudoaneurysm» and «orthopedic surgery». Articles referenced were read selectively and this review included 121 articles. Patient demographics, clinical presentations, diagnostic methods and treatment were reviewed. A total of 131 cases of arterial PSAs was analyzed. There were 82 men with an average age of 50 years old. The commonest clinical presentation was painful swelling (58%). Most patients underwent an arteriography (64%). Arterial injuries were frequently caused by knee arthroplasty (25%) and knee arthroscopy (24%). The most common vascular injuries included geniculate (27%) and popliteal arteries (26%). Surgical (53%) and endovascular (40%) procedures were the commonest therapeutic modalities. Postoperative courses were uneventful in 129 patients (98%). Geniculate and popliteal artery PSAs are the most frequent vascular complications of orthopedic surgery. They must be evoked when faced with a painful swelling and/or pulsatile mass. Arteriography is an ideal option for confirming the diagnosis. It is often performed with embolization to treat small branches PSAs or with stenting graft for those arising from arterial trunks. Alternatively, surgical ligation or repair was still an option.
Compression therapy is a standard use in patients with an advanced chronic venous insufficiency in order to aid venous ulcers or to prevent ulcer recurrence. Nevertheless, there exists only low evidence for the use of compression therapy in patients with uncomplicated varicose veins even though there has been reported a high recommendation. Especially the duration of time remains unclear. The article gives an overview about the actual literature. Overall it seems that a compression therapy after phlebolgical interventions has a benefit. Nevertheless, the evidence is very low and the postoperative use is based on experience. Especially for patients with symptoms and oedema the application of compression stockings may have an advantage.
