Chronická končetinu ohrožující ischemie (CLTI - chronic limb threatening ischemia) je považována za nejzávažnější typ onemocnění periferních tepen. Je definována přítomností chronické ischemické klidové bolesti, ulcerací nebo gangrény, v důsledku uzávěru periferních arteriálních cév. Je spojena s vysokým rizikem velkých amputací, kardiovaskulárních příhod a úmrtí. Léčba pacientů s CLTI výrazně ekonomicky zatěžuje zdravotnické systémy po celém světě. Je předkládán přehled o epidemiologii, patofyziologii, diagnostice a léčbě CLTI.

Vascular causes of exertional lower extremity pain are relatively rare, but may be the answer in athletes refractory to treatment for the more common overuse syndromes of the lower extremities. Important vascular etiologies to be considered are popliteal artery entrapment syndrome (PAES), iliac artery endofibrosis (IAE), popliteal artery aneurysm (PAA), cystic adventitial disease. It is important to differentiate these vascular causes from chronic musculoskeletal syndromes. Because all of these conditions may present with pain or intermittent claudication, imaging is crucial for differentiating them and directing management. The diagnostic workup involves digital subtraction angiography (DSA) or noninvasive vascular studies such as Doppler ultrasound or computed tomography angiography (CTA) or magnetic resonance angiography (MRA) in the provocative positions. Delayed diagnosis can lead to major complications, including acute limb ischemia. Treatment of these vascular abnormalities typically involves surgical correction. Our aim is to provide an overview of these conditions in order to make physicians aware of them and avoid misdiagnosis for timely appropriate management.

Cevni přiciny namahových bolesti dolnich koncetin u sportovců jsou relativně vzacne. Mohou být ale přicinou opakovaných bolestivých stavů při zatěži dolnich koncetin. Mezi důležite cevni patologie, ktere je třeba vzit v uvahu, patři entrapment syndrom poplitealni tepny (PAES), endofibroza ilicke arterie (IAE), aneurysma poplitealni tepny (PAA), cysticka degenerace adventicie poplitealni tepny. Je důležite odlisit tyto vaskularni přiciny od chronických muskuloskeletalnich syndromů. Cevni patologie se projevuji jak klidovými bolestmi, tak intermitentni klaudikaci. Pro diagnostiku jsou zasadni zobrazovaci techniky, ktere jsou urcujici pro vedeni lecby. Diagnosticke postupy zahrnuji digitalni subtrakcni angiografii (DSA) nebo neinvazivni zobrazeni, jako je duplexni sonografie (DUS), angiografie pomoci výpocetni tomografie (CTA) nebo angiografie magnetickou rezonanci (MRA) v provokativnich pozicich. Opožděna diagnoza může vest k zavažným komplikacim, vcetně akutni ischemie koncetin (ALI). Lecba těchto vaskularnich abnormalit obvykle zahrnuje chirurgickou korekci. Cilem clanku je poskytnout přehled o těchto cevnich přicinach namahových bolesti dolnich koncetin a edukovat lekaře, aby se tak vyhnuli nespravne diagnoze kvůli vcasnemu zahajeni lecby. © 2020, CKS.

Background: Carotid endarterectomy is beneficial in symptomatic patients with ≥70% stenosis at the bifurcation of the internal carotid artery. The fact that the duplex ultrasound is widely used, inexpensive and non-invasive for examination of the carotid arteries underlines the importance of high accuracy of this method for grading internal artery stenosis. Patients and Methods: Duplex scans and arteriograms of carotid arteries of 142 patients were reviewed. Peak and end-diastolic velocities of the common and internal carotid arteries were recorded, and the percent stenosis of the internal carotid artery was determined by arteriogram. Receiver-operator characteristic curves of sensitivity, specificity, positive and negative predictive values and accuracy were determined. Results: The recommended criteria for the detection of ≥70% stenosis of the internal carotid artery were: peak systolic velocity in the internal carotid artery ≥215 cm/s, end-diastolic velocity in the internal carotid artery ≥65 cm/s, ratio of peak systolic velocities in the internal and common carotid arteries ≥2.7 and ratio of the end-diastolic velocities of the internal and common carotid arteries ≥3.7. Conclusion: These criteria allow for reliable determination of internal carotid artery stenosis ≥70% by duplex ultrasound.

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Renal denervation (RDN) is a promising therapeutic method in cardiology. Its currently most investigated indication is resistant hypertension. Other potential indications are atrial fibrillation, type 2 diabetes mellitus and chronic renal insufficiency among others. Previous trials showed conflicting but promising results, but the real benefits of RDN are still under investigation. Patients with renal insufficiency and resistant hypertension are proposed to be a good target for this therapy due to excessive activation of renal sympathetic drive. However, only limited number of studies showed benefits for these patients. We hypothesize that in our experimental model of chronic kidney disease (CKD) due to ischemia with increased activity of the renin–angiotensin–aldosterone system (RAAS), renal denervation can have protective effects by slowing or blocking the progression of renal injury.

Purpose. To evaluate the effectiveness of percutaneous mechanical thrombectomy using Rotarex S in the treatment of acute limb ischemia (ALI) in infrainguinal occlusions in a retrospective study of patients treated in our institution. Methods. In this study, we identified a total of 147 ALI patients that underwent mechanical thrombectomy using Rotarex S at our institution. In 82% of the cases, percutaneous thrombectomy was used as first-line treatment, and for the remainder of the cases, it was used as bailout after ineffective aspiration or thrombolysis. Additional fibrinolysis and adjunctive aspirational thrombectomy were utilized for outflow occlusion when required. Procedural outcomes, amputation rate, and mortality at 30 days were evaluated. Results. Of the 147 patients treated with mechanical thrombectomy, Rotarex S was used as first-line treatment in 120 cases and as second-line treatment in 27 cases. Overall, we achieved 90.5% procedural revascularization success rate when combining mechanical thrombectomy with limited thrombolysis for severe outflow obstruction, and 1 death and 3 amputations were observed. We achieved primary success in 68.7% of the patients with the mechanical thrombectomy only, and in 21.8% of the patients, we successfully used additional limited thrombolysis in the outflow. The overall mortality was 0.7% and amputation rate was 2% at 30 days. Conclusion. Percutaneous mechanical thrombectomy as first-line mini-invasive treatment in infrainguinal ALI is safe, quick, and effective, and the performance outcomes can be superior to that of traditional surgical embolectomy.

Acute limb ischemia is a life-threatening condition caused by various etiologies including atherothrombosis and peripheral embolization. However, in young adults other etiologies should also be considered. We report a rare case of a 19-year-old man developing acute limb ischemia of both upper and lower limbs due to prolonged vasospasm. (C) 2017 The Czech Society of Cardiology. Published by Elsevier Sp. z o.o. All rights reserved.

Atherosclerosis is a diffuse disease which may lead to the development of unstable atherosclerotic plaque. Its rupture can result in acute ischemic event. The atherosclerotic plaques with a mobile component are typical presentations of such instability and patients with these plaques are at high risk of acute ischemic events. In the current literature, substantial data regarding the mobile atherosclerotic plaques in carotid arteries and thoracic aorta is published. However there are almost no data concerning the mobile plaques in the peripheral arteries of the lower limbs. We present a rare case of a patient with generalized atherosclerosis, in whom an asymptomatic mobile atherosclerotic plaque in the common femoral artery with a high embolic potential was diagnosed. This plaque was successfully removed by femoral endarterectomy. On the basis of this case, we review the possibilities and limitations of the current imaging methods in detection of mobile plaques in the peripheral arteries. Moreover optimal therapeutic approaches in such patients are discussed.

Background: Ventricular arrhythmias play an important role in cardiovascular mortality especially in patients with impaired cardiac and autonomic function. The aim of this experimental study was to determine, if renal denervation (RDN) could decrease the inducibility of ventricular fibrillation (VF) in a healthy porcine biomodel.Methods: Controlled electrophysiological study was performed in 6 biomodels 40 days after RDN (RDN group) and in 6 healthy animals (control group). The inducibility of VF was tested by programmed ventricular stimulation from the apex of right ventricle (8 basal stimuli coupled with up to 4 extrastimuli) always three times in each biomodel using peripheral extracorporeal oxygenation for hemodynamic support. Further, basal heart rate (HR), PQ and QT intervals and effective refractory period of ventricles (ERP) were measured. Technical success of RDN was evaluated by histological examination.Results: According to histological findings, RDN procedure was successfully performed in all biomodels. Comparing the groups, basal HR was lower in RDN group: 79 (IQR 58; 88) vs. 93 (72; 95) beats per minute (p = 0.003); PQ interval was longer in RDN group: 145 (133; 153) vs. 115 (113; 120) ms (p < 0.0001) and QTc intervals were comparable: 402 (382; 422) ms in RDN vs. 386 (356; 437) ms in control group (p = 0.1). ERP was prolonged significantly in RDN group: 159 (150; 169) vs. 140 (133; 150) ms (p = 0.001), but VF inducibility was the same (18/18 vs. 18/18 attempts).Conclusions: RDN decreased the influence of sympathetic nerve system on the heart conduction system in healthy porcine biomodel. However, the electrophysiological study was not associated with a decrease of VF inducibility after RDN.

Impaired cerebrovascular reactivity (CVR), an important risk factor for future stroke, is affected by a presence carotid stenosis. However, in some cases CVR can be impaired in the absence of carotid stenosis due to several poorly characterized mechanisms. We hypothesized that arterial stiffening as observed in coronary heart disease (CHD) could be associated with alteration in CVR in CHD patients without carotid stenosis. The study population consisted of patients referred for coronary angiography without significant carotid stenosis (<50 %). CVR was evaluated by breath holding index (BHI) measured with transcranial color code duplex ultrasound. Arterial stiffness was assessed by pulse wave velocity (PWV) measured by the oscillometric method. The extent of coronary atherosclerosis was quantified by Gensini score (GS). Out of 186 subjects, sixty-two patients fulfilled the inclusion and exclusion criteria. BHI decreased with increasing PWV (r = -0.47, p<0.001). Decrease in BHI was significantly inversely associated with GS (r = -0.61, p<0.001). GS was associated with PWV (p<0.001). In conclusion, impaired CVR was associated with increased arterial stiffening in CHD patients in the absence of significant carotid stenosis. Thus, we speculate that increased arterial stiffness may at least partially contribute to the pathophysiology of CVR alteration in coronary artery disease.

The following is a case report of a young man with antiphospholipid syndrome, present with a recurrent iliofemoral venous thrombosis and premature peripheral arterial disease. This case report highlights the high risk of recurrent thrombosis upon discontinuation of anticoagulation therapy, particularly in the presence of persistent spontaneously increased aPTT and a high antiphospholipid antibody titer. The case report also reviews the potential of endovascular treatment of iliac vein thrombosis and points out the good 24-month patency rates of stents implanted into the pelvic vein region.Key words: antiphospholipid syndrome - iliofemoral deep vein thrombosis - recurrent thrombosis - accelerated atherosclerosis - peripheral arterial disease.

Objectives: Renal denervation (RDN) is a new expanding technique for treatment of resistant arterial hypertension. This new method has been recently proved to be effective with the Symplicity platform. However, this system is not cooled and represents a potential risk of increased thermal damage to the endothelium and its use is quite limited because of the cost. The Thermocool (TC) irrigated tip catheter is widely available and has been already used for RF ablation in other territories. However, the efficacy and safety of this system for renal denervation is not known. We aimed to compare the efficacy and safety of the TC catheter with the Symplicity system for RDN in a swine model. Design and methods: The swine model was used because of similar renal artery anatomy to human. Anatomic eligibility was confirmed by angiography prior to treatment. 5-6 ablations were delivered to each renal artery. The catheter was introduced via femoral arterial access using 6F sheath (Symplicity) or 8F sheath (TC). Clinical data of the procedure were recorded (energy, impedance, temperature and duration). And biochemical parameters were measured before RFA and direct after the procedure. Results: RDN was performed in 9 pigs. The Symplicity system was used in four cases and the TC platform in five. The average number of effective RF ablation was 5 in each artery in both groups (p=NS). The average RF energy used to achieve significant decrease of impedance was significantly higher for the TC platform (TC 14,4±0,8 W vs Simplicity 8±0W, p<0,0001). The average ablation time for each lesion was identical (120 seconds). The average decrease in impedance was higher with the TC system (TC 19%±0,03 vs Symplicity 11%±0,03, p = 0,02). During RF ablation the maximal temperature increase for the Symplicity system was higher (Tmax Symplicity 57 °C vs Tmax TC 41°C, p< 0,001). The average changes in the concentration of renin, aldosteron, sodium, potassium, urea, creatinin, cystatin C did not significantly differ in both groups (all p=NS). Conclusion: Our preliminary results show that renal denervation using the Thermocool platform is safe and results in lower thermal injury. Therefore, the TC platform can be applied for renal denervation in human renal arteries with similar effects as the Symplicity system. However, future studies must show that this novel approach provides better protection of the endothelium because of lower thermal injury.

Isolated calf vein thrombosis in the population of patients with deep vein thrombosis is found approximately in 10 to 25 % of cases. We present 3 cases of calf vein thrombosis which occurred due to unusual causes. Specific characteristics of this form of thromboembolic disease are discussed and compared to proximal deep vein thrombosis with emphasis to symptoms, risk of complications, prognosis and therapeutic approach.

The CCAAT/enhancer-binding protein alpha, encoded by the intronless CEBPA gene, is a transcription factor that induces expression of genes involved in differentiation of granulocytes, monocytes, adipocytes and hepatocytes. Both mono- and bi-allelic CEBPA mutations were detected in acute myeloid leukaemia and myelodysplastic syndrome. In this study we also identified CEBPA mutations in healthy individuals and in patients with peripheral artery disease, ischaemic heart disease and hyperlipidaemia. We found 16 various deletions with the presence of two direct repeats in CEBPA by analysis of 431 individuals. Three most frequent repeats included in these deletions in CEBPA gene are CGCGAG (493- 498_865-870), GG (486-487_885-886), and GCCAAGCAGC (508-517_907-916), all according to GenBank Accession No. NM_004364.2. In one case we identified that a father with ischaemic heart disease and his healthy son had two identical deletions (493_864del and 508_906del, both according to GenBank Accession No. NM_004364.2) in CEBPA. The occurrence of deletions between two repetitive sequences may be caused by recombination events in the repair process. A double-stranded cut in DNA may initiate these recombination events in adjacent DNA sequences. Four types of polymorphisms in the CEBPA gene were also detected in the screened individuals. Polymorphism in CEBPA gene 690 G>T according to GenBank Accession No. NM_004364.2 is the most frequent type in our analysis. Statistical analysis did not find significant differences in the frequency of polymorphisms in CEBPA in patients and in healthy individuals with the exception of P4 polymorphism (580_585dup according to GenBank Accesion No. NM_004364.2). P4 polymorphism was significantly increased in ischaemic heart disease patients.