This position paper is based on the current German and international guideline recommendations [1] [2] [3] and serves as a short, clinically-oriented guideline for the diagnosis and treatment of patients with diabetes mellitus and peripheral arterial disease (PAD).

Hyperglycemia and insulin resistance contribute to vascular damage and are regulated by different pathophysiological processes. The aim of the study was to systematically investigate the relative contributions of multiple fasting state- and oral glucose tolerance test (oGTT)-derived glycemic traits to carotid intima-media thickness (cIMT), a surrogate parameter of subclinical atherosclerosis, in individuals with increased risk for type 2 diabetes mellitus (T2D). 667 volunteers (417 women and 250 men, mean age 44.1 years), who were free of cardiovascular disease (CVD), were included in this cross-sectional study. Glucose tolerance, insulin sensitivity, insulin secretion and insulin clearance were assessed by frequently sampled 75 g oGTT. CIMT was measured by high-resolution ultrasound. Insulin clearance was associated with cIMT in univariate analysis (ß st = − 0.17, p < 0.0001) and in a stepwise regression analysis on 15 variables possibly affecting cIMT, age (r 2 = 0.3923, p < 0.0001), insulin clearance (r 2 = 0.4564, p < 0.0001), systolic blood pressure (r 2 = 0.4733, p < 0.0001), body mass index (BMI) (r 2 = 0.4804, p = 0.002), gender (r 2 = 0.4831, p = 0.013), and fasting insulin clearance (r 2 = 0.4857, p = 0.030) turned out to be significant determinants of cIMT. In a cross-validated model resulting from this analysis, insulin clearance was found to be an independent determinant of cIMT (ß st = − 0.16, p < 0.0001) even after adjusting for traditional CVD risk factors. Reduced insulin clearance may be an early marker of damage on the vasculature, independent of classical CVD risk factors. Reduced insulin clearance should be considered with regard to vascular insulin resistance.

Aim: The visceral adiposity index (VAI) has been proposed as an estimate of visceral adipose tissue (VAT) mass and as an indicator of VAT dysfunction. Both parameters are associated with cardiometabolic risk, including insulin resistance. In this study, we investigated whether VAI is associated with subclinical atherosclerosis in subjects who were free of cardiovascular disease but were at risk of developing diabetes mellitus. Methods: A total of 731 adults with a median age of 47 years old without diabetes mellitus were included in this cross-sectional study. The anthropometric data, blood pressure, and lipid profiles of 398 women and 333 men were measured. All subjects underwent an oral glucose tolerance test, and carotid intima -media thickness (cIMT) was evaluated by ultrasound. Insulin resistance was estimated using the homeostatic model assessment of insulin resistance (HOMA-IR). Results: VAI and HOMA-IR (beta(st) = 0.44, p < 0.0001), VAI and cIMT (beta(st) = 0.17, p < 0.0001), and HOMA-IR and cIMT (beta(st) = 0.09, p = 0.0127) were correlated with each other. After adjusting for cofounding variables, VAI is still correlated with HOMA-IR (beta(st) = 0.42, p < 0.0001). Furthermore, VAI (beta(st) = 0.07, p = 0.0392) but not HOMA-IR (beta(st )= 0.03, p = 0.37) was correlated with cIMT independently of other established cardiovascular risk factors. Conclusion: The calculation of VAI may provide a better estimation of subclinical atherosclerosis than the calculation of HOMA-IR.

Arteriovenous fistulae are defined as congenital or acquired abnormal direct communications between an artery and a vein leading to abnormal blood circulation. This report describes an unusual manifestation of an acquired peripheral arteriovenous fistula with a high shunt volume of 410 ml/min following a fracture of the 5th finger.

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Increased perivascular fat mass contributes to cardiometabolic risk (CMR). High peribrachial adipose tissue (PBAT) associates with insulin resistance independently of established CMR parameters. It is unknown to what extent periaortic adipose tissue (PAAT) may have a similar impact. In 95 participants, precise quantification of total adipose tissue, PBAT, PAAT, visceral adipose tissue (VAT), and liver fat (LF) content was performed by whole-body magnetic resonance imaging. Insulin sensitivity was determined by oral glucose tolerance test and carotid intima-media thickness (cIMT) by high-resolution ultrasound. In univariate analyses, PAAT correlated with PBAT (β = .65, P < .0001). A negative correlation of PAAT (β = -.35, P = .0002) and PBAT (β = -.43, P < .0001) with insulin sensitivity was observed. While in a stepwise forward regression analysis the relationship of PAAT with insulin sensitivity was no longer significant after adjustment for VAT, LF content, and other CMR factors ( P = 0.42), PBAT still correlated with insulin sensitivity ( r2 = .35, P = .01). The association between PAAT and cIMT (β = .49, P < .0001) remained significant after adjustment for these variables ( r2 = .42, P = .0001). Although PAAT and PBAT strongly correlate, PAAT is not associated with insulin resistance, but with cIMT. Therefore, PAAT and PBAT may act differently as possible modulators of insulin resistance and subclinical atherosclerosis.

We report on a patient with acute dyspnea after several vertebral body interventions, among others a kyphoplasty, that was performed a few days earlier.In the computed tomography we prove a bilateral pulmonary embolism (cement and thrombus). There is no right heart failure. A deep vein thrombosis can be excluded by color-coded vascular ultrasound.The pulmonary embolism is due to bone cement. The cement material is also found paravertebral, intraspinal and intraneuroforaminal. By conservative treatment using therapeutic anticoagulation and analgesic medication, the patient showed a rapid clinical improvement.In patients with cardiopulmonary symptoms after vertebroplasty and kyphoplasty, pulmonary embolism due to bone cement should be considered as a possible cause. The therapy depends on the extent of the cement embolism and the symptoms of the patient.

HISTORY AND ADMISSION FINDINGS:We report on a patient with acute dyspnea after several vertebral body interventions, among others a kyphoplasty, that was performed a few days earlier. INVESTIGATIONS:In the computed tomography we prove a bilateral pulmonary embolism (cement and thrombus). There is no right heart failure. A deep vein thrombosis can be excluded by color-coded vascular ultrasound. DIAGNOSIS, TREATMENT AND COURSE:The pulmonary embolism is due to bone cement. The cement material is also found paravertebral, intraspinal and intraneuroforaminal. By conservative treatment using therapeutic anticoagulation and analgesic medication, the patient showed a rapid clinical improvement. CONCLUSIONS:In patients with cardiopulmonary symptoms after vertebroplasty and kyphoplasty, pulmonary embolism due to bone cement should be considered as a possible cause. The therapy depends on the extent of the cement embolism and the symptoms of the patient.

Circulating trimethylamine N-Oxide (TMAO) levels predict cardiovascular disease (CVD), possibly by impacting on cholesterol metabolism and oxidative stress. Because hepatic TMAO production is regulated by insulin signalling and it is unclear whether and to what extent circulating TMAO levels associate with CVD risk, independently of insulin resistance and its important determinants fatty liver and visceral obesity, we have now addressed this question in 220 subjects who participated in the Tübingen Lifestyle Intervention Program. Visceral fat mass (r = 0.40, p < 0.0001), liver fat content (r = 0.23, p = 0.0005) and TMAO levels (r = 0.26, p < 0.0001) associated positively and insulin sensitivity associated negatively (r = −0.18, p = 0.009) with carotid intima-media thickness (cIMT). Higher TMAO levels (std.−Beta 0.11, p = 0.03) predicted increased cIMT, independently of age, sex and visceral fat mass. While during the lifestyle intervention most cardiovascular risk parameters improved, mean TMAO levels did not change (p = 0.18). However, cIMT decreased significantly (p = 0.0056) only in subjects in the tertile with the largest decrease of TMAO levels (>20%). We provide novel information that increased serum TMAO levels associate with increased cIMT, independently of established cardiovascular risk markers, including insulin resistance, visceral obesity and fatty liver. Furthermore, the decrease of cIMT during a lifestyle intervention may be related to the decrease of TMAO levels.

We report on two pregnant women with dyspnoe and thoracic pain in the context of an ovarian hyperstimulation syndrome.Both patients had pleural effusions. The first patient was diagnosed with pulmonary embolism via computer tomography. In the second patient, thrombosis of the upper part of the body including intracranial thrombosis was revealed via magnetic resonance and ultrasound imaging. In both cases, thrombosis was caused by ovarian hyperstimulation.Therapy included anticoagulation with low molecular weight heparin and a drainage of the pleural effusions. One patient had an abortion in the 8th week of pregnancy, the second patient gave birth to two healthy children.Ovarian hyperstimulation syndrome is a potentially life-threatening disease, which should be considered as a differential diagnosis of causes of thromboembolic events in early pregnancy.

BACKGROUNDThere is a widely approved influence of novel risk factors like the body fat distribution and the associated metabolic syndrome, subclinical inflammation, insulin resistance and prediabetic disturbances in glucose metabolism on the progression of atherosclerosis. Former studies examining normal values for intima-media thickness (IMT) did not consider all of these new study results in detail. We therefore aimed to assess an update on age- and gender-specific normal values for IMT accounting for these novel risk factors.PATIENTS AND METHODSWe evaluated IMT by high-resolution ultrasound (13 MHz) on the far wall of the common carotid artery in 801 subjects without cardiovascular disease (428 women aged 46.2±12.9 years; 373 men aged 47.3±13.3 years). After precise evaluation and exclusion of 14 cardiovascular risk factors, 90% limits of IMT were determined by parametric statistics.RESULTSThe reference limits of IMT according to the age classes 18-29, 30-39, 40-49 and 50-59 years were estimated as 0.47, 0.59, 0.67 and 0.70 mm in women and 0.47, 0.62, 0.72 and 0.80 mm in men.CONCLUSIONSAge and gender-specific normal values for IMT are lower than reported in former studies after additionally accounting for novel cardiovascular risk factors. The still widely regarded upper IMT limit of 1 mm must be strictly regarded as obsolete.

HISTORY AND ADMISSION FINDINGS:We report on two pregnant women with dyspnoe and thoracic pain in the context of an ovarian hyperstimulation syndrome.INVESTIGATIONS:Both patients had pleural effusions. The first patient was diagnosed with pulmonary embolism via computer tomography. In the second patient, thrombosis of the upper part of the body including intracranial thrombosis was revealed via magnetic resonance and ultrasound imaging. In both cases, thrombosis was caused by ovarian hyperstimulation.DIAGNOSIS, TREATMENT AND COURSE:Therapy included anticoagulation with low molecular weight heparin and a drainage of the pleural effusions. One patient had an abortion in the 8th week of pregnancy, the second patient gave birth to two healthy children.CONCLUSIONS:Ovarian hyperstimulation syndrome is a potentially life-threatening disease, which should be considered as a differential diagnosis of causes of thromboembolic events in early pregnancy.

Since the introduction of endovascular aneu- rysm repair (EVAR) in 1991, the endovascular therapy with newest stent grafts has assumed a prominent role in the clinical management of abdominal aortic aneurysms (AAA) with a superior perioperative mortality of EVAR and an equivalent mid-term outcome, compared to open surgery. Newest techniques using chimney or periscope grafts and customized fenestrated and branched stent grafts allow the endovascular treatment of complex para- renal AAA. This article reviews EVAR in the treatment of AAA, evidence based results and advanced indication by newest interventional techniques and technical developments. Key Points: ▶ EVAR has become standard treatment of abdominal aortic aneurysm with equiva- lent results to open surgery. ▶ Technical advancements and the introduc- tion of newest stent grafts continually ex- pand the indication of EVAR. ▶ Chimney- and periscope grafts as well as custom-made prothesis systems allow en- dovascular treatment of complex para- and suprarenal aneurysms.

History and admission findings: We report on a 58-year-old male patient with abdominal and right-sided flank pain, who presented with the picture of an acute abdominal emergency. Investigations: Laboratory tests revealed evidence of an inflammation and a hematuria. In the Doppler duplex ultrasound and computed tomography, chronic idiopathic periaortitis was diagnosed. The inflammatory-fibrosing disease resulted in urine retention and rupture of the fornix of the right kidney. Diagnosis, treatment and course: After surgical implementation of an ureteral stent and initiation of immunosuppressive therapy, it came to an improvement of the symptoms. Conclusions: In the differential diagnosis of an acute abdominal emergency, diseases of the aorta should be taken into account. Especially in male patients with anatomical complications it is important to exclude an inflammatory-fibrosing disease.

HISTORY AND ADMISSION FINDINGS:We report on a young female patient with flank pain and a swelling of the lower limb of the left side.INVESTIGATIONS:In magnetic resonance angiography as well as Doppler-duplex ultrasound an iliofemoral phlebothrombosis of the left side due to vena cava inferior hypoplasia with collateral circulation was diagnosed. Oral contraception could play a role as a trigger. The patient also presented activated protein C resistance/ heterozygous factor V Leiden mutation.DIAGNOSIS, TREATMENT AND COURSE:According to the CaVenT study we treated the patient successfully with catheter-directed thrombolysis. Follow-ups presented a patency of the iliofemoral vein.CONCLUSIONS:In young patients with short duration of a proximal deep vein thrombosis and after exclusion of contraindications a catheter-directed lysis should be considered as a treatment option. The differential diagnostic of a (bilateral) ilio-femoral vein thrombosis in young patients should include an anomaly of the venous system.

Klippel-Trénaunay syndrome (KTS) is a rare congenital anomaly characterized by malformation of lymph and blood vessels as well as growth disturbance of soft tissue and bone. The clinical picture is variable and associated with an increased risk of thromboembolic events mediated by intravascular coagulopathy in venous malformations. Here, we report on a male patient with KTS suffering from recurrent deep vein thrombosis (DVT) and life-threatening bleeding due to consumptive coagulopathy. Furthermore, we describe the successful long-term anticoagulant management with rivaroxaban.

Interventional therapies using angioplasty and stenting of symptomatic stenosis of the proximal supraaortic vessels have evolved as safe and effective treatment strategies. The aim of this paper is to summarize the current treatment concepts for stenosis in the subclavian and brachiocephalic artery with regard to clinical indication, interventional technique including selection of the appropriate vascular approach and type of stent, angiographic and clinical short-term and long-term results and follow-up. The role of hybrid interventions for tandem stenoses of the carotid bifurcation and brachiocephalic artery is analysed. A systematic review of data for angioplasty and stenting of symptomatic extracranial vertebral artery stenosis is discussed with a special focus on restenosis rate.