The role of intraoperative 2D foot perfusion during percutaneous infrainguinal angioplasty in patients with critical limb ischemia

Abstract

Background. Critical limb ischemia (CLI) is an end stage of peripheral arterial disease. Percutaneous transluminal angioplasty (PTA) has gained a mainstream position in treatment of CLI. Frequently, multilevel hemodynamically significant atherosclerotic lesions are detected during PTA in patients with CLI. Therefore, intraoperative decision of intervention level and amount has to be undertaken based on macrovascular images acquired during intraoperative digital subtraction angiography (DSA) analysed by eye. Intraoperative 2D foot perfusion angiography (2DFPA) is a novel post-processing tool integrated in newest generation DSA equipment. It offers an objective quantitative analysis of different flow and contrast density parameters within region of interest (ROI). Consequently, it might become an additional objective intraoperative tool in estimation of operation volume. Aim. To establish basic protocol for 2DFPA in Riga East University Hospital and perform pilot evaluation of the parameters acquired during 2DFPA. Methods. In this case, the control study performed during June to November of 2020, and included 7 patients with CLI and intraoperative 2DFPA. 2DFPA performed through antegrade 6F 23 cm sheath in superficial femoral artery with automated injection volume/rate 15 ml/6 ml/s and fixed position of the foot during procedure. Following pre-intervention and post-intervention perfusion parameters analysed in whole foot ROI: arrival time (AT), time-to-peak (TTP), area under the curve (AuC), peak density (PD); Results. The mean age – 71.5 (54–85) years, 4 males, 3 females. CLI Rutherford class V in all patients. One patient excluded due to foot movements during procedure and noncomparable 2DFPA results. 3 patients underwent PTA of superficial femoral artery, 3 patients – infrageniculate PTA. In 4 PTA procedures defined by operator as successful based on DSA, the following 2DFPA parameters were acquired: decrease of AT and TTP, and increase of PD and AuC was found corresponding with good technical result. 2DFPA showed no improvement of parameters in one PTA defined by operator as successful and in one PTA defined by operator as not successful. Conclusion. 2DFPA is an easy and safe intraoperative analysis tool to be applied, although adaptation of protocol and patient positioning is required. Acquisition of intraoperative perfusion parameters pre- and post-treatment might serve as a marker for operation volume, if the desired perfusion goals are not achieved. Following larger scale trials have to be conducted to establish specific perfusion value ranges as treatment end-points. Medicina (Kaunas) 2021;57(Supplement 1):200 201Medicina (Kaunas) 2021;57(Supplement 1) The role of Transcranial Doppler sonography for neuromonitoring in cardiac surgery with cardiopulmonary bypass Mackevics Davis1, Leibuss Roberts2,3, Oss Elvijs2, Kalejs Martins2,3, Strike Eva2,3, Stradins Peteris2,3 1University of Latvia, Faculty of Medicine, Riga, Latvia 2Riga Stradiņš University, Faculty of Medicine, Riga, Latvia3Pauls Stradiņš Clinical University Hospital, Riga, Latvia Background. In patients undergoing cardiac surgery with cardiopulmonary bypass (CPB), blood pressure (BP) excursions outside the limits of cerebral autoregulation are associated with organ and brain dysfunction. The use of TCD has been reported in intraoperative monitoring of cerebral blood flow and air emboli by providing instant visual feedback. Individualized mean arterial pressure (MAP) management targeted to optimize cerebral autoregulation by TCD might provide a more neuroprotective approach to patient care during CPB than standardized BP management. Aim. The study aimed to analyse MAP excursions during non-pulsatile CPB effects on cerebral blood flow parameters and primary postoperative outcomes. As well as identify possible other factors affecting TCD. Methods. 50 elective cardiac surgeries with CBP performed in a University Clinical Hospital. The right and left middle cerebral artery blood flow velocity was assessed using TCD and analysed for spectrum. Measurement intervals: after anaesthesia induction, 15 minutes after aortic cross-clamping, and 15 minutes after CBP. The average pulsatility index (PI), time-averaged peak velocity (TAPV), resistance index (RI), end-diastolic velocity (EDV), peak systolic velocity (PSV) were recorded and compared. Results and discussion. A total of 50 patients were included. The mean age 64.76 (42–81) years; CPB 101.14 (54–184) minutes; Ejection fraction 52.50 (20–72); Body mass index 29.08 (19.48–44.41); Diabetes occurred in 38 patients; Pulmonary arterial hypertension (PAH) I occurred in 18 patients, 21 patients – PAH II; Blood transfusions were performed in 22 patients; Catecholamines was required in 21 patients; Patients who stayed longer in the ICU had more comorbidities – nine patients stayed in the ICU for 9–65 days (median 4.64). MAP during CPB was 66.18 (50–80). The blood transfusion rate showed no significant differences. Hematocrit was decreased postoperatively (mean 29) compared to preoperative values (mean 37.7); during CPB 25.6. CPB during cardiac surgery has been demonstrated to cause alterations of the cerebral blood flow. RI was affected by gender (p=0.08), type of operation (p=0.09) and CHF (p=0.08); PI was affected by gender (p=0.02), diabetes (p=0.06) and PAH (p=0.02); PSV was affected by presence of diabetes (p=0.04), PAH (p=0.006), heart rate (p=0.04), TAPV (p=0.05); Conclusion. TCD method can be considered for multimodal neuromonitoring in cardiac surgery. TCD can be a useful guiding instrument for adequate hemodynamic parameters, confirming the adequacy of cerebral perfusion strategy or the need for its optimization. Acknowledgements. The authors declare the absence of conflict of interest. Medicina (Kaunas) 2021;57(Supplement 1):201 202Medicina (Kaunas) 2021;57(Supplement 1) Evaluation of STEMI caused by the atherosclerotic disorder of the specific coronary artery Rėkus Algirdas1, Jaruševičius Gediminas2, Aldujeli Ali2 1Lithuanian University of Health Sciences, Faculty of Medicine, Kaunas, Lithuania 2 Lithuanian University of Health Sciences, Department of Cardiology, Kaunas, Lithuania Background. ST-elevation myocardial infarction (STEMI) is an acute condition best treated by percutaneous coronary artery (CA) intervention. This retrospective study attempted to assess the association between STEMI caused by CA and disease risk factors, studies conducted and treatment data. Aim. To evaluate the connections between CA and of STEMI – experienced patients’ data of those admitted to the Lithuanian University of Health Sciences Department of Cardiology. Methods. A retrospective single-centre study was conducted of 745 STEMI patients. Patients were divided into four groups, depending on CA induced STEMI: right coronary artery (RCA), left main artery (LM), left anterior descending (LAD), left circumflex (LCx). Gender, age, history of smoking, diabetes mellitus (DM), obesity, arterial hypertension (AH), TIMI flow before and after reperfusion, total number, length and diameters of stents used, initial laboratory tests: haemoglobin, glucose, creatinine, troponin I (TnI), potassium, leukocytes, total (TC), high (HDC) and low (LDC) – density cholesterol, triglyceride levels (TG) and mortality were evaluated. Chi-square test, Student’s t-test, independent – samples Kruskal- Wallis test, ANOVA were used for analysis. The value of p≤0.05 was considered statistically significant. Results. The study evaluated 756 STEMI patients. No statistical significance was found between the CA and data: gender (p=0.217), age (p=0.466), smoking (p=0.378), DM (p=0.296), obesity (p=0.095), AH (p=0.194), TIMI flow before (p=0.173) and after intervention (p=0.488), number of stents used (p=0.629), initial laboratory tests: glucose (p=0.690), creatinine (p=0.156), TnI (p=0.808), potassium (p=0.185), leukocytes (p=0.912), TC (p=0.217), LDC (p=0.187), TG (p=0.4) and mortality (p=0.461). The statistical significance of the following data was determined: the total length of stents used in RCA was longer than LCx (p=0.03), the total diameter of the stents used in LAD was larger than RCA (p=0.02), the initial haemoglobin concentration was lower in LAD than RCA (p=0.02), HDC was found to be higher in LAD than in RCA (p=0.004). Conclusion. For the RCA, longer stents were used in general than the LCx, but the total stents’ diameter for the LAD was larger than in case of the RCA. The haemoglobin concentration was lower in the LAD than in the RCA. HDC was found in higher concentration among LAD than the RCA. Medicina (Kaunas) 2021;57(Supplement 1):202 203Medicina (Kaunas) 2021;57(Supplement 1) Platelet activity and its correlation with inflammation and cell count readings in chronic heart failure patients with reduced ejection fraction Mongirdienė Aušra1, Laukaitienė Jolanta1,2, Skipskis Vilius3 1Lithuanian University of Health Sciences, Institution Department of Biochemistry, Kaunas, Lithuania 2Lithuanian University of Health Sciences, Cardiology Clinic, University Hospital, Kaunas, Lithuania 3Lithuanian University of Health Sciences, Institute of Cardiology, Laboratory of Molecular Cardiology, Kaunas, Lithuania Background. There has been an increasing interest in the role of inflammation in thrombosis complications in chronic heart failure (HF) patients. The incidence of thrombosis in HF is shown to be the highest in patients classified as NYHA IV. It is stated that inflammation is regulated by platelet-induced activation of blood leukocytes. Aim. The objective of the current study was to compare the platelet and cell count readings in chronic HF with reduced ejection fraction (HFrEF) patients according to NYHA functional class and to evaluate the correlation between those readings. Methods. Total of 185 patients were examined in complete blood cell count, platelet aggregation, C reactive protein (CRP), NT-proBNP, cortisol, fibrinogen concentration. Results. Mean platelet volume (MPV) increased with deterioration of a patient’s state (p<0.005). Lymphocyte count and percent were the lowest in NYHA IV group (p<0.005). Neutrophil percent and count, monocyte percent and count were the highest (p<0.045) in NYHA IV. ADP and ADR-induced platelet aggregation was higher in NYHA III group compared to NYHA II and I group (p<0.023). NYHA functional class correlated with MPV (r=0.311, p=0.0001), lymphocyte count (r=-0.186, p=0.026), monocyte count (p=0.172, p=0.041), and percent (r=0.212, p=0.011). CRP concentration correlated with NT-proBNP (r=0.203, p=0.005). MPV correlated with fibrinogen concentration (r=0.244, p=0.004). Neutrophil count correlated with fibrinogen concentration (r=0.308, p=0.0001), evening cortisol concentration (r=0.256, p=0.009), and CRP (r=0.378, p=0.0001). Lymphocyte percent correlated with fibrinogen concentration (r=-0.174, p=0.03), CRP (r=-0.220, p=0.028), and evening cortisol concentration (r=-0.246, p=0.012). Monocyte percent correlated with fibrinogen concentration (r=0.175, p=0.03). Monocyte count correlated with morning cortisol, fibrinogen concentration (r=0.279, p=0.004 and r=0.315, p=0.0001, respectively) and CRP (r=0.315, p=0.0001). Conclusion. 1) MPV could be considered as additional reading reflecting patient’s condition; use of MPV identifying patients at risk of hypercoagulable state should be evaluated in more extensive studies; 2) increasing neutrophil and monocyte count could indicate a higher inflammatory state in chronic HFrEF. Acknowledgements. The authors declare the absence of conflict of interest. No outside funding has been received for the current study. Medicina (Kaunas) 2021;57(Supplement 1):203