warfarin and Intermittent-Claudication

Peripheral vascular disease is the rarest vascular complication in systemic lupus erythematosus. Some theories propose that immune complexes may promote inflammation in the vessel, and disrupt it in a manner that may cause ischemia.. A 14-year-old Asian girl presented with intermittent claudication as the chief complaint followed by discoloration of her left big toe for 2 weeks prior to admission. Her medical history showed that 1 month prior to admission she had photosensitivity, rash, and arthralgia, with positive antinuclear antibody test, positive anti-double-stranded DNA test, positive anti-ribosomal protein P, and complement C4 (7.4 mg/dL); she was diagnosed as having systemic lupus erythematosus and started therapy. A local examination of her left toe showed black discoloration, low pulsation, localized tenderness, and decreased sensation. Laboratory results showed C-reactive protein of 1.16 mg/dL and D-dimer of 2.28 uG/mL. A computed tomography angiogram showed near total occlusion of her popliteal artery; critical limb ischemia was confirmed. Peripheral arteriography was performed with invasive strategy. After the procedure, the flow was improved to distal, but there was inflammation in the vessel, so we decided to stop the procedure because of the risk of dissection. Our patient was given atorvastatin and warfarin, and we maximized her systemic lupus erythematosus therapy with prednisone. There were two follow-ups. The first follow-up was 1 week after the procedure. Our patient attended her first follow-up at our out-patient department with no symptoms and improvement in her toe's discoloration; warfarin was stopped, and clopidogrel and cilostazol were added for thrombus prevention therapy, she was then scheduled for debridement. The second follow-up was done 2 months after the first follow-up and discoloration was improved. The third follow-up, 5 months after the second follow-up, showed improvement.. Critical limb ischemia is a rare complication of systemic lupus erythematosus that requires immediate treatment. Due to our limited resources, we improvised a strategy to achieve the best possible outcome in our patient by using a combination of invasive treatment and medication.

Topics: Adolescent; Anticoagulants; Endovascular Procedures; Female; Hallux Valgus; Humans; Immunosuppressive Agents; Intermittent Claudication; Ischemia; Lower Extremity; Lupus Erythematosus, Systemic; Treatment Outcome; Warfarin

Atherosclerotic peripheral arterial disease (PAD) is a common disorder usually associated with silent or symptomatic arterial disease elsewhere in the circulation and a cluster of cardiovascular risk factors inducing atheroma progression and/or thrombotic complications. Because of these strong clinical associations, especially with coronary heart disease, the ankle-brachial pressure index (ABPI) is of prognostic significance. The clinical management of IC should include relief of symptoms combined with prevention of secondary cardiovascular complications, e.g. acute thrombotic events causing limb- or life-threatening ischaemia, which are often due to atherosclerotic plaque rupture leading to thrombotic vessel occlusion. Many patients with PAD do not receive an optimum package of secondary prevention, tailored to include maximum cholesterol reduction, BP and glycaemic control, ACE inhibition and single or combination anti-platelet therapy. This review considers recent information from large secondary prevention trials, e.g. the PAD subgroups within the HOPE, CAPRIE and statin studies. Slowing progression of atherosclerosis, and inducing stabilisation and regression of atheromatous plaques, is now feasible using long-term combination drug therapy. The phrase angle quotation mark, leftangle quotation mark, leftconservative therapyangle quotation mark, rightangle quotation mark, right, popular among vascular surgeons, implies a passive minimal-intervention strategy of surveillance and lifestyle advice; such terminology is perhaps no longer appropriate since considerable improvements in survival are likely to accrue if all patients with PAD, especially those with low ABPI, receive vigorous, titrated medical therapies, tailored to individual patients, as part of an evidence-based secondary prevention regime.

Topics: Angiotensin-Converting Enzyme Inhibitors; Anticoagulants; Aspirin; Blood Pressure; Coronary Disease; Forecasting; Humans; Hypolipidemic Agents; Intermittent Claudication; Peripheral Vascular Diseases; Risk Factors; Smoking; Warfarin

A recent retrospective study showed that the ischemic consequences of femoropopliteal bypass graft occlusion were more severe with polytetrafluoroethylene (PTFE) than with vein. This study examines this conclusion and whether oral anticoagulation therapy reduces the degree of ischemia after occlusion of PTFE and vein femoropopliteal bypass grafts.. Four hundred two patients who underwent femoropopliteal bypass grafting (233 PTFE and 169 vein) were randomized to a postoperative regimen of either warfarin (international normalized ratio, 1.4 to 2.8) and aspirin (WASA; 325 mg daily) therapy or aspirin alone (ASA) therapy. The grade of acute ischemia at the time of graft occlusion was assessed with the Society of Vascular Surgery recommended reporting standards (I, viable; II, threatened). Early graft occlusions (<30 days) were excluded.. There were 100 graft occlusions (67 PTFE and 33 vein) during a mean follow-up period of 36 months (PTFE) and 39 months (vein). Forty-eight patients were randomized to WASA therapy, and 52 were randomized to ASA therapy. The patients were well matched for age, atherosclerotic risk factors, operative indication, and preoperative ankle-brachial index. Overall, a greater percentage of the PTFE occlusions caused grade II ischemia than did the vein graft occlusions (48% versus 18%; P =.005). The ankle-brachial index at the time of graft occlusion was significantly lower in the PTFE grafts than in the vein grafts (0.28 versus 0.45; P =.001). The patients with PTFE who were undergoing WASA therapy at the time of graft occlusion had less grade II ischemia than did those patients who were undergoing ASA therapy (28% versus 55%; P =.057). However, the incidence rate of severe ischemia after graft occlusion remained greater with PTFE grafts and WASA therapy as compared with all the vein grafts (28% versus 18%). The vein graft occlusions had the same incidence rate of grade II ischemia with WASA therapy as with ASA therapy (20% versus 17%; P = 1.0).. The ischemic consequences of femoropopliteal bypass graft occlusion are worse with PTFE than with vein. Treatment with WASA therapy lessens the severity of acute ischemia after the occlusion of PTFE graft as compared with ASA therapy but not to the degree seen with vein graft occlusion. Occlusion of femoropopliteal vein grafts is seldom accompanied by severe ischemia and is not improved with WASA therapy.

Topics: Aged; Amputation, Surgical; Anticoagulants; Aspirin; Boston; Femoral Vein; Fibrinolytic Agents; Follow-Up Studies; Graft Occlusion, Vascular; Humans; Incidence; Intermittent Claudication; International Normalized Ratio; Ischemia; Leg; Maryland; Middle Aged; Polytetrafluoroethylene; Popliteal Vein; Prospective Studies; Severity of Illness Index; Texas; Treatment Outcome; Warfarin

We analyzed the short- and long-term results for patients undergoing thrombolysis of occluded infrainguinal bypass grafts at our institution over a 62-month period.. Thirty-one patients with 40 episodes of graft thrombosis in 33 grafts managed by thrombolysis were retrospectively reviewed. The effects of graft age, material, and anatomy, symptoms, treatment, anticoagulation, and occlusion duration were evaluated for impact on patency after thrombolysis. Dose and duration of therapy with use of the technique of pulse-spray thrombolysis was assessed.. Thrombolysis successfully reestablished patency in 92% of grafts treated. Mean lysis time and urokinase dose were 118 minutes and 607,000 units, respectively. Responsible lesions were identified and treated by angioplasty or surgery in 35 of 37 cases. The patency rate after thrombolysis was 28% at 30 months, and the secondary patency rate was 46% at 18 months. Duration of occlusion, symptoms, treatment, graft anatomy, and prior graft revision did not impact on patency. Mean secondary patency was 21.5 months in grafts in place over 1 year and 7.0 months in grafts in place for less than 1 year. Mean secondary patency was 23.8 months in polytetrafluoroethylene grafts and 8.4 months in vein grafts. The limb salvage rate was 84% at 30 months, and the patient survival rate was 84% at 42 months.. Pulse-spray thrombolysis is effective in rapidly recanalizing thrombosed infrainguinal grafts. Grafts failing in the first year after placement should generally be replaced, reserving thrombolysis and revision for grafts greater than 1 year old. Vein grafts tolerate thrombosis less well than synthetic conduits and have decreased long-term patency.

Topics: Adult; Aged; Angioplasty; Arteriovenous Shunt, Surgical; Combined Modality Therapy; Female; Follow-Up Studies; Graft Occlusion, Vascular; Humans; Intermittent Claudication; Ischemia; Leg; Life Tables; Male; Middle Aged; Polytetrafluoroethylene; Popliteal Vein; Prosthesis Failure; Recombinant Proteins; Reoperation; Retrospective Studies; Survival Rate; Thrombolytic Therapy; Tibial Arteries; Time Factors; Tissue Plasminogen Activator; Urokinase-Type Plasminogen Activator; Vascular Patency; Warfarin

Topics: Adult; Anticoagulants; Antihypertensive Agents; Cilostazol; Drug Therapy, Combination; Femoral Artery; Fibrinolytic Agents; Humans; Hypertension; Intermittent Claudication; Leg; Male; Pain; Physical Exertion; Ramipril; Tetrazoles; Treatment Outcome; Warfarin

The purpose of this study was to examine the outcome of patients in whom an infrainguinal bypass graft failed.. This was a retrospective analysis of consecutive patients undergoing infrainguinal bypass grafting in a single institution over 8 years.. Six hundred thirty-one infrainguinal bypass grafts were placed in 578 limbs in 503 patients during the study period. The indication for surgery was limb-threatening ischemia in 533 patients (85%); nonautologous conduits were used in 259 patients (41%), and 144 (23%) were repeat operations. After a mean follow-up of 28 +/- 1 months (median, 23 months; range, 0-99 months), 167 grafts (26%) had failed secondarily. The rate of limb salvage in patients with graft failure was poor, only 50% +/- 5% at 2 years after failure. The 2-year limb salvage rate depended on the initial indication for bypass grafting: 100% in patients with claudication (n = 16), 55% +/- 8% in patients with rest pain (n = 49), and 34% +/- 6% in patients with tissue loss (n = 73; P <.001). The prospect for limb salvage also depended on the duration that the graft remained patent. Early graft failure (<30 days; n = 25) carried a poor prognosis, with 2-year limb salvage of only 25% +/- 10%; limb salvage was 53% +/- 5% after intermediate graft failure (<2 years, n = 110) and 79% +/- 10% after late failure (>2 years, n = 15; P =.04). Multivariate analysis revealed shorter patency interval before failure (P =.006), use of warfarin sodium (Coumadin) postoperatively (P =.006), and infrapopliteal distal anastomosis (P =.01) as significant predictors for ultimate limb loss.. The overall prognosis for limb salvage in patients with failed infrainguinal bypass grafts is poor, particularly in patients with grafts placed because of tissue loss and those with early graft failure.

Topics: Aged; Arteriovenous Shunt, Surgical; Blood Vessel Prosthesis Implantation; Female; Follow-Up Studies; Graft Occlusion, Vascular; Humans; Intermittent Claudication; Leg; Limb Salvage; Male; Multivariate Analysis; Prognosis; Retrospective Studies; Risk Factors; Time Factors; Vascular Patency; Warfarin

Antiphospholipid syndrome (APS) has been well defined in adults; however, primary nontraumatic arterial thrombosis owing to this entity is unusual in the pediatric population. The authors report a case of APS with lower extremity arterial thrombosis who had discolored feet since delivery.

Topics: Antibodies, Anticardiolipin; Anticoagulants; Antiphospholipid Syndrome; Arterial Occlusive Diseases; Aspirin; Child, Preschool; Collateral Circulation; Heparin, Low-Molecular-Weight; Humans; Immunoglobulin G; Immunosuppressive Agents; Intermittent Claudication; Leg Ulcer; Male; Prednisolone; Skin Diseases, Vascular; Thrombophilia; Warfarin

With the advent of the angiographic balloon catheter, transluminal angioplasty has become a more effective procedure for the alleviation of symptoms of peripheral ischemia. In the past two and a half years we have performed this procedure on over 208 iliac and femoral arteries. One hundred twenty iliac arteries were dilated. Of these, 86% remained patent at one year and 83% at two years. Eighty-eight femoral arteries were dilated. Of these, 75% remained patent at one year and 67% at two years. These vessel survival rates are slightly less than those following surgery. However, the morbidity from transluminal angioplasty is very low and the mortality is essentially zero.

Topics: Adult; Aged; Angioplasty, Balloon; Anticoagulants; Aspirin; Female; Femoral Artery; Follow-Up Studies; Humans; Iliac Artery; Intermittent Claudication; Male; Middle Aged; Vascular Resistance; Warfarin

Two cases of acute aortic thrombosis, a previously unreported complication of antithrombin III deficiency, are reported. Both patients had abnormally low antithrombin III levels, which improved to normal levels with warfarin ;sodium therapy. The possibility of antithrombin III deficiency should be considered in young patients with acute arterial thrombosis.

Topics: Acute Disease; Adult; Antithrombin III; Antithrombin III Deficiency; Aorta, Abdominal; Aortic Diseases; Female; Humans; Infarction; Intermittent Claudication; Kidney; Male; Thrombosis; Warfarin

Topics: Aged; Animals; Cattle; Diabetic Angiopathies; Female; Femoral Artery; Humans; Intermittent Claudication; Knee; Leg Ulcer; Male; Middle Aged; Pain; Popliteal Artery; Postoperative Complications; Radiography; Rest; Thrombosis; Transplantation, Heterologous; Warfarin

Topics: Aorta, Abdominal; Dextrans; Endarterectomy; Female; Femoral Artery; Follow-Up Studies; Hematoma; Hemorrhage; Humans; Intermittent Claudication; Ischemia; Leg; Male; Popliteal Artery; Postoperative Complications; Pulmonary Embolism; Saphenous Vein; Surgical Wound Infection; Thrombosis; Vascular Surgical Procedures; Warfarin

Topics: Adult; Age Factors; Aged; Angiography; Blood Vessel Prosthesis; Diabetes Complications; Dicumarol; Female; Femoral Artery; Fluorocarbon Polymers; Follow-Up Studies; Heparin; Humans; Iliac Artery; Intermittent Claudication; Ischemia; Leg; Male; Methods; Middle Aged; Popliteal Artery; Postoperative Complications; Sex Factors; Thrombosis; Transplantation, Autologous; Transplantation, Homologous; Vascular Diseases; Veins; Warfarin