Peripheral vascular disease (PVD) is defined by insufficient blood flow to limbs and can result in pain, gangrene, and amputation. Minimally invasive angioplasty treatments for PVD are common but suffer from high failure rates. We conducted three studies: 1) a systematic review to describe methods of intraoperative blood flow assessment; 2) a retrospective cohort study to describe the correlation between outpatient blood flow assessment and clinical outcomes; and 3) a prospective observational study to describe the reliability and association between intraoperative blood flow assessment and clinical outcomes. While limb blood flow is routinely assessed before and after interventions, intraoperative assessment has not been well described. Postoperative blood flow assessments are strongly correlated with clinical outcomes. Intraoperative blood flow assessment is feasible and strongly correlated with clinical outcomes. Intraoperative blood flow assessment may be a useful tool to guide intraoperative decision making.

Bakgrund: Claudicatio Intermittens är vanligt förekommande hos äldre personer och ger upphov till fysiska och psykiska besvär såsom försämrad gångförmåga och sämre livskvalite. Fysisk aktivitet är en viktig fysioterapeutisk behandlingsmetod som har visat goda resultat för patientgruppen. Därför är det viktigt att sammanställa aktuell evidens för att öka och tillgängliggöra ny kunskap. Syfte: Att undersöka det vetenskapliga underlaget för fysisk aktivitet som behandling och dess effekt på gångförmåga och livskvalitet hos patienter med claudicatio intermittens. Metod: Studiens design var litteraturstudie. En litteratursökning efter randomiserade kontrollerade studier genomfördes i databasen PubMed. De utvalda studiernas kvalitet granskades enligt PEDro-skalan och tillförlitligheten av resultatet bedömdes utifrån ”Bedömning av den sammanvägda tillförlitligheten i systematiska översikter”. Resultat: Sex studier inkluderades i litteraturstudien. Bäst resultat gällande gångförmåga och livskvalitet fick grupperna som genomgick endovaskulär revaskularisering i kombination med en intervention som innehöll fysisk aktivitet. Samtliga studier fick hög kvalitet från granskningen enligt PEDro. Tillförlitligheten av det sammanvägda resultatet bedömdes enligt ”Bedömning av den sammanvägda tillförlitligheten i systematiska översikter” vara låg. Konklusion: Kombinationen av endovaskulär revaskularisering och fysisk aktivitet hade positiv effekt på utfallsmåttet gångförmåga och livskvalitét hos patienter med claudicatio intermittens, men ingen skillnad mellan olika sorters fysisk aktivitet framgick. Fler studier av hög kvalitet som jämför liknande interventioner behövs för att med hög tillförlitlighet kunna avgöra vilken behandling som ger bäst effekt. / Background: Intermittent claudication is common in the elderly population and causes physical and psychological problems such as impaired walking ability and poorer quality of life. Physical activity is an important physiotherapeutic method that has shown promising results for this population. Therefore, it is important to summarize current evidence in order to increase new knowledge and make it available. Purpose: The aim of this literature study was to examine the scientific evidence for physical activity as a treatment, and its effect on walking capacity and quality of life in patients with intermittent claudication  Method: The design of the study was literature study. A literature search for randomized controlled trials was conducted in the PubMed database. The quality of the included studies was examined by the PEDro scale, and the reliability of the results was assessed with ”Bedömning av den sammanvägda tillförlitligheten i systematiska översikter”. Result:  Six studies were included in the literature study. The best results regarding walking ability and quality of life were obtained by the groups that underwent endovascular revascularization in combination with an intervention that included physical activity. All studies received high quality according to PEDro. According to with ”Bedömning av den sammanvägda tillförlitligheten i systematiska översikter”, the reliability of the combined results was considered low. Conclusion: The combination of endovascular revascularization and physical activity had a positive effect on the outcome measures walking ability and quality of life in patients with intermittent claudication. No difference between different types of physical activity could be seen. More studies of high quality comparing similar interventions are needed to be able to determine, with high reliability, which treatment produces the best effect.

Résumé : Les patients diabétiques ont plus de risques d’être amputés d’une jambe en raison d’une plus faible néovascularisation suite à une ischémie. Nous avons montré une association entre une plus faible réponse angiogénique du VEGF chez les souris diabétiques (DM) et une augmentation de l’expression de SHP-1, pouvant être activée par les récepteurs (AT[indice inférieur 1]/AT[indice inférieur 2]). La délétion du récepteur AT[indice inférieur 2] chez des souris favorise l’angiogenèse dans le muscle ischémique, mais son rôle en condition diabétique demeure inconnu. Notre objectif est de vérifier si la délétion du récepteur AT[indice inférieur 2] chez des souris DM favorise l’angiogenèse suivant l’induction d’une ischémie. Des souris DM de type 1 déficientes (KO) ou non pour le récepteur AT[indice inférieur 2] ont été utilisées. L’ischémie a été induite par la ligature de l'artère fémorale. La perfusion sanguine a été mesurée pendant 2 ou 4 semaines avant la récolte des tissus. Les effets de l’ischémie sur l’expression des récepteurs AT[indice inférieur 1] et AT[indice inférieur 2], des phosphatases SHP-1, SHP-2 et PTP1B, ainsi que l’état de la voie de signalisation du VEGF ont été mesurés. Un essai phosphatase a aussi été effectué suite à l’immunoprécipitation de SHP-1 chez des BAECs stimulés au CGP42112A. Quatre semaines après la chirurgie, le flot sanguin dans le muscle ischémique des souris DM AT[indice inférieur 2]KO s’est rétabli plus rapidement (80%) comparativement à une récupération de 47% chez les souris DM contrôles. L’expression des facteurs pro-angiogéniques (HIF-1α et VEGF) était similaire dans tous les groupes après 2 semaines d’ischémie, mais diminuée chez les DM et retournait à un niveau basal chez les DM-AT[indice inférieur 2]KO après 4 semaines, suggérant un reperfusion plus rapide chez ces souris. La phosphorylation de Akt était aussi plus faible chez les souris DM contrôles mais était rétablie chez les souris AT[indice inférieur 2]KO après 4 semaines d’ischémie. L'expression de SHP-1 était doublée dans le muscle ischémique des souris DM, en comparaison aux souris non DM, un effet absent chez les souris DM AT[indice inférieur 2]KO. L’expression de SHP-2 et PTP1B ne variait pas chez les souris DM sauvages et AT[indice inférieur 2]KO. De plus, l’expression des récepteurs AT[indice inférieur 1] et AT[indice inférieur 2] est augmentée chez les souris DM sauvages en comparaison aux souris NDM. La stimulation du récepteur AT[indice inférieur 2] chez les BAECs a permis d’augmenter l’activité phosphatase de SHP-1. Nos résultats suggèrent que l’expression élevée d’AT[indice inférieur 2] chez les souris DM mène à la surexpression et/ou l’activation de SHP-1, inhibant le signal angiogénique issu du VEGF et empêchant la reperfusion sanguine suite à l’ischémie. / Abstract : Ischemia due to narrowing of femoral artery and distal vessels is a major cause of peripheral arterial disease and morbidity affecting patients with diabetes. We have previously reported that the inhibition of the angiogenic response to PDGF and VEGF in diabetic mice (DM) is associated with the increase expression of SHP-1, a protein that can be activated by the AT[subscript 2] receptor. It has been shown that the deletion of AT[subscript 2] receptor in mice promotes angiogenesis within the ischemic muscle, but its role in diabetic condition remains unknown. Our hypothesis is that AT[subscript 2] receptor induced SHP-1 which contributed to inhibition of pro-angiogenic factor actions in DM mice during ischemia. Non-DM and DM AT[subscript 2] null mice underwent femoral artery ligation. Blood perfusion was measured every week up to 4 weeks post-surgery. Expression of AT[subscript 1] and AT[subscript 2] receptors, SHP-1, SHP-2 and PTP1B, and VEGF pathway was evaluated. A phosphatase assay was executed to assess SHP-1 activity in bovine aortic endothelial cells (BAECs) following CGP42112A stimulation. Blood flow in the ischemic muscle of DM AT[subscript 2]KO mice recovered faster and up to 80% four weeks following the surgery, compared to a 47% recovery in DM mice. After four weeks, the expression of pro-angiogenic factors (HIF-1α and VEGF) was similar in each group after two weeks but diminished in the DM and remained at a basal state in the DM-AT[subscript 2]KO after four weeks suggesting a faster recovery process in these mice. Akt phosphorylation was also diminished in the DM mice but restored in DM AT[subscript 2]KO after four weeks of ischemia. SHP-1 expression was two times more elevated in DM compared to NDM mice, an effect that was not seen in AT[subscript 2]KO mice. SHP-2 and PTP1B expression did not varied in DM wildtype and AT[subscript 2]KO mice. Also, expression of AT[subscript 1] and AT[subscript 2] receptor was upregulated by diabetes in wildtype mice. Stimulation of AT[subscript 2] receptor in BAECs caused increased SHP-1 activity. Our results suggest that elevated expression of the AT[subscript 2] receptor in DM mice lead to up-regulation/activation of SHP-1, inhibiting the VEGF angiogenic signal causing diminished blood flow reperfusion following ischemia.

Vascular disease is the leading cause of global disease burden, but substantial gaps in our knowledge regarding family history of vascular disease, peripheral arterial disease (PAD) and acute aortic disease persist. Prospective, population-based data in these neglected areas may be useful in diagnosis, risk prediction, prognosis and clinical management of vascular disease. The Oxford Vascular Study (OXVASC) is an ongoing prospective, population-based study of vascular disease in all territories in Oxfordshire, UK, which started in 2002. The study population comprises all 91,106 individuals registered with nine general practices. Multiple overlapping methods of “hot” and “cold” pursuit are used to identify all patients with acute vascular events. I have shown that patients with acute coronary syndromes (ACS) and a history of myocardial infarction (MI) in both parents are 6 times more likely to have siblings with MI than those ACS patients with no parental history of MI, whereas, parental stroke does not predict stroke in siblings among TIA/stroke patients. Maternal history of MI is more common in women than men with ACS. Premature maternal MI is strongly associated with premature MI in females and males. I have also shown that maternal stroke is more common than paternal stroke in female ACS patients, and that family history of stroke is as common in patients with ACS as in patients with TIA/stroke. However, I showed that these associations between family history and MI or stroke cannot be explained by disease localisation or disease severity on coronary angiography. In both primary and secondary prevention settings, PAD indicates a high risk of future events. I have shown that, although acute PAD events account for only 7% of acute vascular events at 1 year, they account for 12% of acute vascular deaths. Acute peripheral arterial events are more aggressive in terms of risk factor profile, mortality and morbidity than other vascular disease. Half of patients with incident PAD had history of vascular disease. Incidence and severity of PAD events generally increases with age, and severity of disease predicts mortality. I have shown that incidence of ruptured abdominal aortic aneurysm (RAAA) and aortic dissection increased steeply with age, and 5-year mortality rates were 74% and 65% for RAAA and aortic dissection respectively. I have also shown that the true population-based incidence of acute aortic dissection is similar to previous estimates of incidence, implying that it is accurately diagnosed and coded, and that retrospective data analysis produces valid estimates of incidence.

Estudos sugerem que a periodontite possa ser um fator de risco para o início, desenvolvimento e desfecho da aterosclerose, por meio de mecanismos bacterianos e imunoinflamatórios. Objetivo: Avaliar a influência do tratamento periodontal (TP) em pacientes com doença arterial obstrutiva periférica (DAOP) e periodontite, correlacionando o perfil inflamatório apresentado por esses pacientes após o TP. Materiais e Métodos: Parâmetros clínicos periodontais (índice de placa IP, índice gengival IG, profundidade de sondagem PS, nível clínico de inserção NCI), e os marcadores imunológicos IL-1β, TNF, IL-6, IL-17, IFN-γ, MMP-8, V-CAM-1 e E-selectina foram analisados em fluido crevicular gengival (FCG) e soro desses pacientes (DAOP/DP) (n=25) após TP completo. As amostras de FCG foram coletadas em 3 tempos: no baseline, 45 e 90 dias após o tratamento e de soro nos tempos: baseline e 90 dias. Após reavaliação do tratamento periodontal não cirúrgico, aos 45 dias, foi realizado a o tratamento cirúrgico nos pacientes que apresentaram bolsas residuais 5 mm. Os parâmetros hematológicos de glicemia em jejum, hemoglobina glicada, triglicérides, colesterol total e frações em sangue periférico foram obtidos no baseline e aos 90 dias. Um grupo com DAOP, mas sem doença periodontal (DAOP) (n=15) foi conduzido, em paralelo, para verificação do padrão de melhora. Resultados: Não foram encontradas reduções significativas no perfil lipídico, glicêmico e inflamatório após o TP nos períodos analisados (p > 0.05). No entanto, observou-se correlação moderada positiva aos 45 dias, do NCI em relação aos níveis de 1Lη (r=0,532; p=0,0157) e aos 90 dias, entre o NCI e IL-17 (r=0,501; p=0,0243), ambas no FCG. No soro também foi observada correlação positiva moderada entre a redução do NCI e diminuição da MMP-8 (r=0,621; p=0,0035) aos 90 dias. Conclusão: O TP repercutiu na redução local das citocinas inflamatórias relacionadas à doença periodontal e na redução sistêmica da MMP-8, que é um mediador importante no processo de ruptura das placas ateroscleróticas / Several studies suggest that periodontitis may be a risk factor for the onset and development of atherosclerosis, through bacterial and immunological mechanisms. Objective: To evaluate the influence of periodontal treatment (PT) in patients with peripheral arterial disease (PAD) and periodontitis and to correlate the inflammatory profile presented by these patients after PT. Materials and Methods: Periodontal clinical parameters (plaque index - PI, gingival index - GI, probing depth - PD, clinical attachment level - CAL) and immunological parameters IL-1β, TNF, IL-6, IL-17 , IFN-γ, MMP-8, V-CAM-1 and E-selectin were analyzed in gingival crevicular fluid (GCF) and serum of these patients (PAD /PD) (n = 25) after complete PT. The GCF samples were collected in 3 times: baseline, 45 and 90 days after treatment and serum at baseline and 90 days. After reassessment of the non-surgical periodontal treatment, at 45 days, the surgical treatment was performed in patients with residual pockets 5 mm. Hematologic parameters of fasting glycemia, glycated hemoglobin, triglycerides, total cholesterol, LDL cholesterol and HDL in peripheral blood were obtained at the baseline and 90 days. A group with PAD, but without periodontal disease (PAD) (n = 15) was conducted in parallel to verify the improvement pattern. Results: There were no significant reductions in the lipid, glycemic and inflammatory profile after PT in the analyzed periods (p> 0.05). However, a moderate positive correlation was observed at 45 days for CAL in relation to the GCF levels of 1L-1 (r = 0.532, p = 0.0157) and between the CAL at 90 days of IL-17 (r = 0.501, p = 0.0243). Moderate positive correlation was also observed in the serum between the reduction of CAL and decrease of MMP-8 (r = 0.621; p = 0.0035) at 90 days. Conclusion: PT has repercussions on the local reduction of inflammatory cytokines related to periodontal disease and on the systemic reduction of MMP-8, which is an important mediator in the process of atherosclerotic plaque rupture

Doença cardiovascular é uma causa importante de morte em pacientes em diálise. Doença arterial obstrutiva periférica (DAOP) é um fator prognóstico de doença cardiovascular. Índice de pressão tornozelo-braquial (ITB) é um método não invasivo usado para o diagnóstico de DAOP. A diferença entre ITB pré e pós diálise ainda não foi formalmente testada e foi um dos objetivos deste estudo. Além disso, nós avaliamos o ITB como marcador de mortalidade em pacientes incidentes em hemodiálise. ITB foi obtido por método oscilométrico automático em uma população de pacientes incidentes em hemodiálise. Este estudo foi desenhado para testar a aplicabilidade da determinação do ITB com o uso de 2 aparelhos oscilométricos simultâneos de pressão arterial (Omron Corp 705 CP Corp, Tokyo, Japan) comparando pré e pós diálise assim como lados direito e esquerdo. 123 pacientes (85 homens e 38 mulheres) idade 53±19 anos foram incluídos. Medidas de pressão arterial do lado direito e do lado esquerdo apresentaram médias semelhantes (p=0,565), assim como em 3 sessões consecutivas de diálise, tempo 1, 2 e 3 (coeficiente de variação menor que 5). Nenhuma diferença foi encontrada entre ITB pré e pós diálise, tanto no lado direito quanto no lado esquerdo, assim como nos tempos 1, 2 e 3. Em pacientes com história de DAOP, o ITB pré vs. pós diálise teve uma tendência a ser significante no lado direito (p=0,088). Durante o período de acompanhamento, 31 pacientes morreram. Estes pacientes eram mais velhos e apresentaram maiores níveis de cálcio. Diabetes, hipertensão e qualquer outro fator de risco cardiovascular não estiveram associados com mortalidade. Pacientes com ITB baixo (<0,9) e alto (>1,3) apresentaram maior mortalidade que pacientes com ITB normal (0.9-1.3). Foi concluído que medidas de ITB pré e pós diálise mostraram baixa variabilidade. O ITB em pacientes com história de DAOP deve ser avaliado com mais atenção. A presente técnica usada neste estudo pode ser usada como marcador de mortalidade em pacientes incidentes em hemodiálise / Cardiovascular disease is an important cause of death in patients on dialysis. Peripheral arterial disease (PAD) is a prognostic factor for cardiovascular disease. Ankle-brachial index (ABI) is a non-invasive method used for the diagnosis of PAD. The difference between ABI pre and post dialysis was not yet formally tested, and it was one objective of this study. In addition, we evaluate the ABI in predict mortality in incident patients on hemodialysis. ABI was assessed by automated oscillometric device in incident patients on hemodialysis. This study was designed to assess the applicability of ABI determination with the employment of two automated oscillometric blood pressure devices simultaneously (Omron Corp 705 CP Corp, Tokyo, Japan), comparing pre and post dialysis as well right and left side. The measurements were done by using two oscillometric devices simultaneously to measure blood pressure in upper and lower extremities. 123 patients (85 men and 35 women), age 53±19 years were enrolled. Blood pressure measurements on the right side and on the left side presented similar means (p=0,565), as well in the consecutive sessions, times 1, 2 and 3, (coefficient of variation lower than 5). We found no difference in ABI pre and post dialysis, either on the right or left side, as well in times 1, 2 and 3. In patients with history of PAD, the ABI pre vs. post dialysis was of borderline significance on the right side (p=0.088). During the follow-up period, 31 patients died. These patients were older and presented higher calcium level. Diabetes, hypertension and any other cardiovascular risk factor were not associated with mortality. Patients with either low ABI or high ABI (<0.9 and >1.3, respectively) presented higher mortality than patients with normal ABI (0.9-1.3). We concluded that ABI measured pre and post dialysis offered low variability. The ABI in patients with history of PAD should be evaluating with caution. The current method applied in this study can predict mortality among incident patients on hemodialysis

A doença arterial periférica (DAP) é uma síndrome degenerativa multifatorial que acomete principalmente idosos e tem como principais características a redução da qualidade de vida e o aumento da mortalidade cardiovascular. Dentre as limitações funcionais impostas pela doença, a mais evidente é a piora da capacidade locomotora decorrente da claudicação intermitente (períodos alternados de isquemia e reperfusão). Atualmente não existem tratamentos farmacológicos capazes de bloquear a progressão da DAP, caracterizada pela redução da capacidade oxidativa muscular, excessivo estresse oxidativo e consequente acúmulo de aldeídos reativos no leito afetado. Com base nisso, o presente trabalho visou caracterizar o papel da enzima aldeído desidrogenase 2 na progressão da DAP. Para isso caracterizamos o modelo animal de DAP, e verificamos que camundongos C57Bl/6 após a cirurgia de oclusão de fluxo apresentam redução da atividade catalítica da enzima ALDH2. Fato acompanhado por uma intolerância ao esforço físico, atrofia e prejuízo na contratilidade muscular, além de desarranjo sarcomérico e mitocondrial. Em modelo de cultura celular, a inativação da enzima ALDH2, após hipóxia e reoxigenação levou à prejuízo na angiogênese e disfunção mitocondrial. Mesmo fenômeno observado nos animais DAP tratados com inibidor, que desenvolveram disfunção mitocondrial e pobre resposta à atividade física. Em modelo de genético de redução da atividade da enzima ALDH2, foi possível ver exacerbada disfunção muscular. Baseado nesses resultados, acreditamos que a enzima ALDH2 desempenha um importante papel na progressão da doença arterial periférica, sendo um possível alvo terapêutico. / Peripheral arterial disease (PAD) is a multifactorial disease which mainly affects elderly reducing quality of life and increasing cardiovascular mortality. Among the functional limitations imposed by the disease, the progressive worsening of locomotor capacity arising from intermittent periods of ischemia and reperfusion, are related to reduced muscle oxidative capacity, excessive oxidative stress and consequent accumulation of reactive aldehydes in the affected leg. We recently demonstrated that lipid peroxidation induced-toxic aldehydes accumulation contributes to ischemic heart disease progression. Interestingly, oxidation of these aldehydes through aldehyde dehydrogenase 2 (ALDH2) activation is cardioprotective. Based on that, this work characterizes the role of ALDH2 during PAD progression. The PAD animal model presents decreased skeletal muscle ALDH2 enzyme activity associated with exercise intolerance, muscle atrophy, poor muscle contraction, skeletal muscle sarcomeric disruption and giant mitochondrial accumulation. After ALDH2 inhibitor treatment, cell culture submitted to hypoxia/reoxygenation stress showed no angiogenesis and mitochondrial dysfunction. Similar data was seen at animal model, where PAD mice treated with ALDH2 inhibitor shows mitochondrial dysfunction, greater atrophy and affected physical exercise response. Also, transgenic mice for ALDH2 (which has a reduced ALDH2 activity) submitted to PAD showed a smaller muscle contraction, compared to wild type PAD mice. Our data points to ALDH2 as an important therapeutic target to develop new therapy strategies to counteract PAD progression.

Peripheral arterial disease (PAD) is a disease which may cause gradual narrowing and possibly congestion of arteries that are responsible for nourishing the lower limbs. Most often this condition develops consequently with atherosclerosis. The most advanced stage of PAD is called critical limb ischemia. The changes induced by atherosclerosis affect not only the lower limb arteries, but at the time of the diagnosis of PAD all arteries in the body are already affected. Therefore PAD belongs among cardiovascular diseases and its diagnosis is a negative prognostic factor of the overall cardiovascular risk. The aim of treatment interventions is to reduce complications that accompany this ailment and their impact on the patient's life. The aim of the thesis was to find out to what extend the patients are informed about the causes of PAD, options of its treatment and the impact of prevention and life style on the overall prognosis of the disease. The first objective of the thesis is to find out if patients are aware of the risks of PAD treatment, one of which is leg amputation. The second objective is to find out whether the patients are sufficiently informed about their condition. The third objective is to evaluate whether patients follow the prescribed treatment. The fourth objective is to find out whether patients are willing to change their life style in order to eliminate the risk of lower limb amputation. A part of interviews with patients was to educate them about their condition, the necessity of following the treatment regimen and the impact of lifestyle on the affected leg prognosis. At the end, the interviewed received educational handouts with information about the most important suggested procedures to follow. The practical part of the thesis is based on qualitative research. The data was collected in semi-structured interviews. The interviews were conducted in two steps. The first step was to educate patients about PAD and distribute informational handouts. The second round of interviews took place intentionally several months after the first ones. Their purpose was to assess the impact of education on patients' compliance with treatment and regimen. The research shows the majority of the interviewed were well-informed about the crucial aspects of their condition and treatment procedures. The participants understood the given information and considered it satisfactory. However, it was surprising that patients had not looked for information themselves. Simultaneously, it was ascertained that most of the respondents were aware of the prognosis and risks related to the treatment. The two-step interviews showed some respondents were not aware of the causes of their disease. It can be therefore assumed that their ignorance of the risk factors and their impact on the development of the disease is the reason why patients do not give enough importance to the suggested treatment regimen. Furthermore, it was found out that they had not look for a substitute solution if they are not able to follow the recommended treatment regimen. The results of this thesis show that although the elimination of the risk factors is crucial for patients' future they do not pay enough attention to them. There are two aspects to it; either patients trivialize the potential risks or are apathetic or are not sufficiently informed. It is hard to have some impact on patients' apathy and trivialization of their condition. Nevertheless, it is possible to influence the second aspect, which is the subject of the final part of the thesis and the educational handout. As was discovered during the interviews, the information provided by doctors during ambulatory treatment is not thorough and does not include practical advice how to follow treatment regimen. Patients should be informed by nurse either personally or during the sessions. In this way the patient should be also selfmotivated in their treatment.

Doença cardiovascular é uma causa importante de morte em pacientes em diálise. Doença arterial obstrutiva periférica (DAOP) é um fator prognóstico de doença cardiovascular. Índice de pressão tornozelo-braquial (ITB) é um método não invasivo usado para o diagnóstico de DAOP. A diferença entre ITB pré e pós diálise ainda não foi formalmente testada e foi um dos objetivos deste estudo. Além disso, nós avaliamos o ITB como marcador de mortalidade em pacientes incidentes em hemodiálise. ITB foi obtido por método oscilométrico automático em uma população de pacientes incidentes em hemodiálise. Este estudo foi desenhado para testar a aplicabilidade da determinação do ITB com o uso de 2 aparelhos oscilométricos simultâneos de pressão arterial (Omron Corp 705 CP Corp, Tokyo, Japan) comparando pré e pós diálise assim como lados direito e esquerdo. 123 pacientes (85 homens e 38 mulheres) idade 53±19 anos foram incluídos. Medidas de pressão arterial do lado direito e do lado esquerdo apresentaram médias semelhantes (p=0,565), assim como em 3 sessões consecutivas de diálise, tempo 1, 2 e 3 (coeficiente de variação menor que 5). Nenhuma diferença foi encontrada entre ITB pré e pós diálise, tanto no lado direito quanto no lado esquerdo, assim como nos tempos 1, 2 e 3. Em pacientes com história de DAOP, o ITB pré vs. pós diálise teve uma tendência a ser significante no lado direito (p=0,088). Durante o período de acompanhamento, 31 pacientes morreram. Estes pacientes eram mais velhos e apresentaram maiores níveis de cálcio. Diabetes, hipertensão e qualquer outro fator de risco cardiovascular não estiveram associados com mortalidade. Pacientes com ITB baixo (<0,9) e alto (>1,3) apresentaram maior mortalidade que pacientes com ITB normal (0.9-1.3). Foi concluído que medidas de ITB pré e pós diálise mostraram baixa variabilidade. O ITB em pacientes com história de DAOP deve ser avaliado com mais atenção. A presente técnica usada neste estudo pode ser usada como marcador de mortalidade em pacientes incidentes em hemodiálise / Cardiovascular disease is an important cause of death in patients on dialysis. Peripheral arterial disease (PAD) is a prognostic factor for cardiovascular disease. Ankle-brachial index (ABI) is a non-invasive method used for the diagnosis of PAD. The difference between ABI pre and post dialysis was not yet formally tested, and it was one objective of this study. In addition, we evaluate the ABI in predict mortality in incident patients on hemodialysis. ABI was assessed by automated oscillometric device in incident patients on hemodialysis. This study was designed to assess the applicability of ABI determination with the employment of two automated oscillometric blood pressure devices simultaneously (Omron Corp 705 CP Corp, Tokyo, Japan), comparing pre and post dialysis as well right and left side. The measurements were done by using two oscillometric devices simultaneously to measure blood pressure in upper and lower extremities. 123 patients (85 men and 35 women), age 53±19 years were enrolled. Blood pressure measurements on the right side and on the left side presented similar means (p=0,565), as well in the consecutive sessions, times 1, 2 and 3, (coefficient of variation lower than 5). We found no difference in ABI pre and post dialysis, either on the right or left side, as well in times 1, 2 and 3. In patients with history of PAD, the ABI pre vs. post dialysis was of borderline significance on the right side (p=0.088). During the follow-up period, 31 patients died. These patients were older and presented higher calcium level. Diabetes, hypertension and any other cardiovascular risk factor were not associated with mortality. Patients with either low ABI or high ABI (<0.9 and >1.3, respectively) presented higher mortality than patients with normal ABI (0.9-1.3). We concluded that ABI measured pre and post dialysis offered low variability. The ABI in patients with history of PAD should be evaluating with caution. The current method applied in this study can predict mortality among incident patients on hemodialysis

Orientador: Wilson Nadruz Junior / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-22T09:54:44Z (GMT). No. of bitstreams: 1 Gemignani_Tiago_D.pdf: 3089084 bytes, checksum: aedee263d43b0d61197caea8058ed566 (MD5) Previous issue date: 2013 / Resumo: As artérias dos membros inferiores são submetidas a uma maior sobrecarga hemodinâmica na posição ortostática. Este estudo avaliou os efeitos da variação postural sobre a tensão circunferencial na parede das artérias poplíteas, carótidas e braquiais, bem como investigou a correlação entre a tensão circunferencial e a presença de placas ateroscleróticas nestas artérias em uma população com fatores de risco cardiovascular. Duzentos e três indivíduos (118 mulheres e 85 homens) com fatores de risco cardiovascular (tabagismo, hipertensão arterial e diabetes mellitus) foram estudados clínica e laboratorialmente, sendo a pressão arterial mensurada nos braços e panturrilhas, tanto em posição supina como ortostática. As artérias foram avaliadas por ultrassonografia, enquanto a tensão circunferencial foi calculada de acordo com a Lei de Laplace. Nos indivíduos participantes, observou-se a presença de placas ateroscleróticas em 47%, 29% e 0% das artérias poplíteas, carótidas e braquiais, respectivamente. As medidas de tensão circunferencial em artérias carótidas não foram associadas à presença de placas ateroscleróticas após ajuste pelas variáveis confundidoras. Por outro lado, as análises de regressão logística e de modelo linear geral mostraram, após ajuste pelas variáveis confundidoras, que a tensão circunferencial sistólica ortostática foi o único parâmetro hemodinâmico local que demonstrou correlação significativa com placas ateroscleróticas poplíteas em toda amostra estudada. Na análise específica por sexos, apesar da correlação positiva com a presença de placas ateroscleróticas poplíteas em ambos os sexos, a tensão circunferencial sistólica ortostática exibiu associação independente com placas ateroscleróticas somente em mulheres, após ajuste pelas variáveis confundidoras. Em conclusão, a tensão circunferencial ortostática poplítea e não a em posição supina, é associada com placas ateroscleróticas em artérias poplíteas, particularmente em mulheres. Estes dados sugerem que a posição ortostática pode desempenhar uma função importante na aterogênese das artérias dos membros inferiores, modificando as forças hemodinâmicas locais, podendo, contudo, haver diferença entre os sexos / Abstract: Lower limb arteries are exposed to higher hemodynamic burden in erectile posture. This study evaluated the effects of body posture on popliteal, carotid and brachial circumferential wall tension (CWT) and investigated the relationship between local CWT and atherosclerotic plaques in subjects with cardiovascular risk factors. Two hundred and three subjects (118 women and 85 men) with cardiovascular risk factors (smoking, hypertension or diabetes mellitus) underwent clinical and laboratory analysis and had their blood pressure measured in the arm and calf in supine and orthostatic positions. Arteries were evaluated by ultrasound analysis, while CWT was calculated according to Laplace's law. Among the enrolled participants, 47%, 29% and none presented popliteal, carotid and brachial plaques, respectively. Carotid CWT measurements were not associated with local plaques after adjustment for potential confounders. Conversely, general linear model and logistic regression analyses adjusted for potential confounders demonstrated that peak orthostatic CWT was the only local hemodynamic parameter showing significant relationship with popliteal plaques in the whole sample. In gender-specific analyses, although positively correlated with popliteal plaques in both genders, local peak orthostatic CWT exhibited an independent association with popliteal plaques after adjustment for potential confounders only in women. In conclusion, popliteal CWT measured in orthostatic posture, rather than in supine position, is associated with popliteal atherosclerotic plaques, particularly in women. These findings suggest that orthostatic posture might play a role in the atherogenesis of leg arteries by modifying local hemodynamic forces and that there may be gender differences in this regard / Doutorado / Clinica Medica / Doutor em Clínica Médica