Biomedical subjects
Publications and source records attributed to E Minar.
We describe the case of a young woman who developed fatal pulmonary embolism during thrombolytic therapy of a deep pelvic and leg vein thrombosis, despite the insertion of a temporary vena cava filter. So the opinion that the insertion of inferior vena cava filters always prevents lethal pulmonary embolism caused by thrombi of the deep vein system must be revised.
The objective of this study was to determine the effects of transvenous regional guanethidine block in the treatment of patients with critical finger ischemia. Twenty-seven patients (17 collagen vascular disease, four thromboangiitis obliterans, three embolism, three atherothrombosis) presenting with ischemic rest pain and/or ulcerations of the fingers received a single block with 5 mg guanethidine injected in 60 mL into the clinically more affected hand under 30 minutes of arterial arrest. Marked hyperemia was induced in the treated upper limb, increases (p < 0.01) in finger blood flow, finger skin temperature, and laser Doppler flux were higher and longer lasting than in forearm blood flow, persisting for a whole month. Effects in patients with ischemic finger ulcers were less pronounced than in those without, yet statistically significant increases of all evaluated parameters were observed in these patients too. No effects were seen in the contralateral untreated upper limb or in systemic blood pressure. Subjective symptoms (reduction of rest pain, numbness, vasospastic attacks) were improved in 25/27 (92.6%) patients, ischemic rest pain disappeared in 20/27 (74.1%), and complete healing of finger tip ulcerations within 1 month was achieved in 10/12 (83.3%) affected patients. No side effects were observed. This described method combines good clinical efficacy with lack of undesirable side effects and can be repeated easily. Therefore, this technique is recommended for broader clinical use.
BACKGROUND: To evaluate colour duplex sonographic guidance of local lysis of occlusions in the femoropopliteal region. METHODS: Thirteen consecutive patients (8 female, mean age 67) with peripheral artery disease with acute and subacute occlusions in the superficial femoral or popliteal artery were included in this study. The lesions were identified by colour duplex ultrasound (Acuson 128 XP/10) After anterograde puncture the guidewire was advanced through the arterial lesions under B-mode image control. The Mewissen Infusion Catheter and a Katzen infusion wire were then accurately positioned within the lesion under B-mode image control. The fibrinolytic drugs were then inserted into the occlusions, initially 2.5 mg rt-PA as a bolus followed by Urokinase (50,000 IU/h) for 24 hours. After control duplex sonography (over 24 hours) the additional angioplasty was performed either under fluoroscopic or exclusively under ultrasound guidance. RESULTS: Eleven of 13 patients with occlusions in the femoro-popliteal region were partially recanalised after ultrasound guided local lysis and after the additional angioplasties (nine under fluoroscopic and three under ultrasound guidance) the arteries were completely recanalised. CONCLUSIONS: Our data show that not only is the positioning of the catheter and the guidewire for local lysis exclusively under colour duplex guidance possible, but also the surveillance of the local lysis and the additional angioplasty. In the case of any complications, however, easy access to angiography should be possible.
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BACKGROUND: Different therapies in consecutive patients (1987-1992) with chronic critical limb ischemia at a department of medical angiology, their short- and long-term outcome were investigated. PATIENTS AND METHODS: 190 patients (112 males, 78 females; age: 67 +/- 12 years); 78 in grade II, 112 in grade III according to Rutherford's classification. Therapeutic regimen: 1. vascular recanalisation by percutaneous transluminal angioplasty [PTA], local or systemic lysis; 2. surgical vascular reconstruction in case of impossibility or failure of catheter procedures; 3. prostanoids and/or antibiotics; 4. local wound treatment including amputations. RESULTS: Vascular recanalisation was attempted in 156/190 (82.1%): PTA in 116/190, surgical vascular reconstruction in 50/190, local in 24/190 and systemic lysis in 8/190 patients. Prostanoids were applied in 89/190 and antibiotics in 73/190 patients. At the time of dismissal 164/190 (86.3%) patients were clinically improved; 11/190 (5.8%) unchanged, 13/190 (6.8%) had undergone major amputations and 2/190 (1.1%) had died. After 2.6 +/- 2.2 years 77 of the 141 patients, who were still alive, were reexamined. Among these 77 patients 84.4% were in grade 0 or 1, 15.6% in chronic critical limb ischemia. Furthermore 13.0% had been amputated since dismissal. Forty-nine of 190 (25.8%) patients had died 3.2 +/- 1.9 years after dismissal from hospital. CONCLUSION: Catheter techniques, mostly PTA, is possible in the majority of patients with chronic critical limb ischemia. Cooperation with vascular surgeons in case of technical impossibility or failure of catheter recanalisation is mandatory. Such a regimen yields satisfactory short- and long-term results and a low rate of complications.
Ticlopidine is increasingly used in the secondary prophylaxis in patients with arterial occlusive diseases. Neutropenia is a well known side effect of this drug. We report a case of a 73 year old woman who was admitted because of severe prolonged ticlopidine induced leucopenia. The past medical history included an immunocytoma of the IgM-kappa type diagnosed seven years ago with less than 10% infiltration of the bone marrow and a chronic hepatitis C. On admission the white cell count was 1000/microL. Ticlopidine was stopped. The white cell count did not increase within one week, thus filgastrim was applied on two consecutive days. The leucocyte count promptly increased to 6000/microL but consecutively dropped within the next fortnight again to levels below 500/microL forcing daily filgastrim application for another 9 days. Four months after the initiation of the therapy with filgastrim the patient had a white cell count of 4300/microL. We therefore conclude that in patients with a history of potentially bone marrow suppressing diseases the use of ticlopidine has to be carefully weighed against possible myelosuppressive effects.
Interstitial ciprofloxacin concentrations were measured by microdialysis in inflamed foot lesions of non-insulin-dependent diabetes mellitus patients following intravenous administration of 0. 2 g of ciprofloxacin. Interstitial ciprofloxacin concentrations were significantly lower than corresponding serum concentrations. There was no significant difference in the penetration of ciprofloxacin into inflamed and unaffected tissue (area under the concentration-time curve(infection)/area under the concentration-time curve(unaffected tissue) = 0.99 +/- 0.15 [mean +/- standard error], n = 6). Thus, inflammation appears to have little or no effect on the penetration of ciprofloxacin into tissue.
A G20210A transition in the prothrombin gene is a common risk factor of venous thrombosis. The risk of recurrent venous thromboembolism in carriers of the 20210A allele is unknown and guidelines for secondary thromboprophylaxis in these patients are not available. In a prospective multicenter trial, 492 patients with a history of objectively documented venous thromboembolism were followed for a mean observation time of 24+/-16 months after discontinuation of oral anticoagulants. Forty-two patients (8.5%) were carriers of the 20210A allele. Three of the 42 patients with the G20210A mutation (7%) and 54 of 450 patients without the mutation (12%) experienced recurrent venous thrombosis. At 24 months, the probability of recurrence was 8% (95% CI 0-16.7) in patients with the mutation and was 12.2% (95% CI 8.8-15.6) in patients without the mutation. In conclusion, the risk of early recurrent venous thromboembolism is not higher in patients with the G20210A mutation than in those without the mutation. Therefore, long-term secondary thromboprophylaxis with oral anticoagulants in heterozygous carriers of the 20210A allele is not justified.
PURPOSE: To investigate the reasons for endoleaks after transluminal infrarenal abdominal aneurysm management and the potential for transluminal interventions in subsequent management. METHODS: Prospective analysis of 50 consecutive patients undergoing endovascular aneurysm repair at a single institution with Stentor and Vanguard grafts from March 1995 to March 1997. SETTING: Academic teaching hospital. RESULTS: Two procedures were converted for other reasons than leak. In the remaining 48 successful procedures endoleaks were detected in 11 (22.9%): proximal aortic leak (2.1%), distal aortic leak (8.3%), iliac leak (12.5%). Leaks were treated at the initial procedure in five patients, resulting in 87.5% excluded aneurysms. Twelve and a half per cent were discharged with a primary leak. Redo was performed on all iliac leaks within 7 weeks. All aortic leaks showed spontaneous thrombosis within 3 months, but reappeared with local aneurysm expansion. Aortic redo-procedures were performed by proximal tubular extension or converting a tube graft into a bifurcation graft. All rescue procedures were successful. Secondary leaks have been observed twice in this series, both treated by endovascular means. CONCLUSIONS: Endovascular treatment of primary and secondary endoleaks is possible, and may be a safe alternative to a difficult open procedure.
PURPOSE: To evaluate in a pilot study the feasibility and efficacy of endovascular brachytherapy for prophylaxis of restenosis after femoropopliteal percutaneous transluminal angioplasty (PTA) without stent implantation in a group of patients with a high risk of restenosis. MATERIALS AND METHODS: Ten patients (six women, four men; mean age, 68 years) with long-segment (mean length, 16 cm; range, 9-22 cm) restenosis underwent PTA followed by endovascular irradiation with high-dose-rate afterloading of an iridium-192 rod. A dose of 12 Gy was targeted to the inner intimal layer of the vessel. Follow-up examinations until 12 months after PTA included measurement of the ankle-brachial index, color duplex ultrasonography (US) with calculation of the peak velocity ratio, and intraarterial angiography when recurrence was suspected. RESULTS: Irradiation was technically feasible in all patients without complications. In six patients, the dilated and irradiated segment remained widely patent at color US, with corresponding excellent hemodynamic and clinical results after 12 months. In four patients, clinical and laboratory findings indicated recurrence and arteriography demonstrated restenosis with a diameter reduction of 60%, 70%, 80%, or 90%. CONCLUSION: Considering the negative selection of patients with a high risk of restenosis, the results of our pilot study are promising concerning the possibility of reduction of restenosis by means of endovascular brachytherapy after long-segment femoropopliteal PTA without stent implantation. The value of this approach should now be determined definitively in randomized trials.
We report the first case of a successful stent placement under color coded ultrasound guidance alone in the superficial femoral artery of a 73-year-old woman suffering from intermittent calf claudication following restenosis after an uncomplicated angioplasty five months previously. Because of a hemodynamically residual stenosis after three attempts at dilatation, a percutaneous transluminal angioplasty and stent insertion were performed under the sole guidance of color coded ultrasound. The intervention was performed without complication and at the six-month follow-up examination, the patient was symptom-free and the stent was morphologically intact and hemodynamically functional. This case shows that successful stent placement under ultrasonic guidance alone, without fluoroscopic control is possible, provided that there is adequate sonographic visualization.
Heparin-induced thrombocytopenia is an immuno-mediated life-threatening side effect of heparin therapy which poses difficulties in diagnosis and major therapeutic problems. Heparin must be instantly discontinued. We describe the case of a 60-year-old male patient with type II heparin-induced thrombocytopenia, complicated by progressive deep venous thrombosis and pulmonary embolism. He failed to improve when therapy was continued with a low molecular weight heparin (Fragmin) and high doses of intravenous immunoglobulins were administered. The test for heparin-dependent platelet aggregation was positive for unfractionated heparin and low molecular weight heparin, but negative for the heparinoid Org 10172. During subsequent anticoagulant therapy with Org 10172 for seven days the number of platelets increased rapidly and the patient recovered. Nine months later Org 10172 was used again in this patient for thrombosis prophylaxis without any adverse effects. In patients with heparin-induced thrombocytopenia requiring immediately acting anticoagulant therapy, Org 10172 can be considered as an effective alternative drug to unfractionated and low molecular weight heparins.
PURPOSE: This study investigated the accuracy of color duplex sonography (CDS) compared with anterograde intraarterial digital subtraction angiography in the evaluation of the tibioperoneal arteries in patients with peripheral arterial occlusive disease. METHODS: Fifty consecutive patients with femoropopliteal obstruction were examined immediately before planned percutaneous transluminal angioplasty. All CDS examinations were performed by one observer; the angiograms were interpreted independently by two readers (A1, A2). We compared agreement concerning judgement of the dominant crural artery (suitable for an eventual femorocrural bypass operation) and judgement of the severity of arterial lesions. RESULTS: Concerning judgement of the dominant artery, the interobserver agreement between the two readers of the angiograms was better (kappa value, 0.76) than the agreement between CDS versus A1 (0.61) and CDS versus A2 (0.56). However, the differences were not statistically significant. The results were independent (no significant differences in the kappa values) of the following criteria: presence of diabetes; clinical stage of peripheral arterial occlusive disease; kind of femoropopliteal obstruction; and status of the popliteal artery. Concerning the evaluation of the severity of arterial lesions, the kappa values were significantly higher (p < 0.05) for A1 versus A2 (posterior tibial, 0.87; anterior tibial, 0.79; peroneal, 0.52) than for CDS versus A1 (0.51; 0.46; 0.07) and CDS versus A2 (0.35; 0.38; -0.05). The sensitivity of CDS (vs A1 as reference) for detecting a hemodynamically relevant arterial lesion (stenosis or occlusion) was 100% in the posterior tibial artery, 78% in the anterior tibial artery, and 92% in the peroneal artery. CONCLUSION: Compared with intraarterial anterograde digital subtraction angiography, the value of CDS-with its currently used technology-for evaluation of the dominant lower leg artery suitable for an eventual femorocrural bypass operation in patients who have femoropopliteal obstruction is limited. It cannot replace an accurate preoperative angiogram for the routine clinical practice, and its use should be restricted to special cases (such as patients with a history of severe allergic reaction to contrast media or of severely impaired kidney function). CDS is also limited in the accurate judgement of the morphologic features of the runoff arteries in their full length in patients with peripheral arterial occlusive disease.
OBJECTIVES: To assess the early experience with the transfemorally placed modular endovascular MinTec graft (TPEG) for abdominal aortic aneurysm (AAA). DESIGN: One single centre prospective evaluation of the endograft procedure as well as early postoperative results. SETTING: An academic teaching hospital. PATIENTS: 30 consecutive patients treated during a period of 15 months. RESULTS: Peri- and postoperative morbidity and mortality were evaluated according to the recommendations of the Ad Hoc Committee on Reporting Standards. The endograft procedure was successful in 28 patients (93.4%); two patients (6.6%) needed conversion into open conventional y-graft replacement; one patient died 36 days following intervention from multiple organ failure. Another patient died from pancreatitis unrelated to the implantation. Endoleaks were treated by "overstenting" or distal extension of the endografts, but conversions were unnecessary. Five severe adverse events were noted in four patients. CONCLUSIONS: TPEG is a feasible but technically demanding procedure, requiring both surgical techniques and catheter skills. The potential for less operative morbidity and simpler aneurysm management compared to conventional open surgery may be present. Close follow-up of patients is necessary to understand the development and treatment of endoleaks.
OBJECTIVES: To compare the costs of endovascular aneurysm treatment versus open surgery during the perioperative period. METHODS: Retrospective analysis of a consecutive series of 44 patients undergoing infrarenal abdominal aneurysm repair from February 1995 to March 1996 at a university teaching hospital. RESULTS: No endovascular procedure was converted to open repair. Operative time was shorter for endovascular treatment (207.6 min vs. 229.1 min, n.s.), as well as postoperative intensive care unit stay (ICU, 22.7 h vs. 55.0 h, p = 0.017) and the postoperative recovery period (5.6 days vs. 13.3 days, p < 0.001). Open surgery generated significantly more costs (25,374.07 ECU vs. 22,268.78 ECU, p < 0.001), despite evaluation and a more expensive endovascular procedure (10,699.48 ECU vs. 4032.01 ECU, p < 0.001). During the study, costs for open surgery exceeded the cost for endovascular treatment by 13.95%. CONCLUSIONS: Endovascular aneurysm treatment is cost effective and less expensive than open surgery. The main reason for cost saving is faster patient recovery after surgery, associated with a shorter LOS in the patients treated with endovascular procedure.
Thromboprophylaxis with oral anticoagulants up to six months is established in patients after a first venous thromboembolic event (VTE). The risk of recurrent VTE is still considerable thereafter, and it is uncertain whether some patients might benefit from extended anti-coagulation. We performed a prospective, multicenter trial (4 thrombosis centers) and evaluated in 380 patients with a first or recurrent VTE (patients with a deficiency of antithrombin, protein C, protein S or plasminogen; cancer; or an antiphospholipid antibody syndrome were excluded) the risk of recurrence after discontinuation of secondary thromboprophylaxis with oral anticoagulants. It was the aim of the study to evaluate whether patients, with factor V Leiden are at an increased risk of recurrent VTE. 112 (29.5%) patients were carriers of factor V Leiden (26.9% heterozygous, 2.6% homozygous). After a median observation time of 19.3 months the overall recurrence rate of VTE was 9.9%. Recurrent deep vein thrombosis and/or pulmonary embolism occurred in 26 of 268 patients without factor V Leiden (9.7%) and in 10 of 112 patients with factor V Leiden (8.9%). The probability of recurrent VTE two years after discontinuation of oral anticoagulants was 12.4% (95% CI 7.8-17) in patients without factor V Leiden and was 10.6% (95% CI 3.8-17.4) in carriers of the mutation. This difference was statistically not significant. Patients with factor V Leiden are not at a higher risk of recurrent VTE within two years after discontinuation of oral anticoagulants than patients without factor V Leiden. Balancing the risk of recurrent VTE and bleeding from oral anticoagulants, patients with factor V Leiden are not likely to benefit from oral anticoagulant therapy extended beyond six months.
BACKGROUND: The following study was designed to evaluate the effectiveness and safety of ultrasound guided compression therapy (UGCT) of iatrogenic postcatheterization pseudo-aneurysms (PA) on the one hand and to justify the usefulness of the routine colour duplex control of the puncture site following transfemoral catheterization, on the other hand. MATERIAL AND METHODS: During the study period 142 patients with (PA) following transfemoral catheterization were identified by means of colour duplex examination Eighty of these 142 patients were identified during a routine colour duplex control of the puncture site the day after PTA/angiography because of peripheral arterial occlusive disease (PAOD) [group A]; the remaining 62 patients with symptomatic groins were referred from other departments [group B]. RESULTS: In 8 patients of group B UGCT was considered to be contra-indicated, they were primarily treated by surgical repair of the PA. A total of 134 patients (group A 80 patients, group B 54 patients) underwent an UGCT. In total the success rate of UGCT was in group A 100% and in group B 78%. 12/54 patients (all group B) with failure of UGCT underwent a secondary surgical repair of the PA. Within group B there was a negative correlation between delay of diagnosis/UGCT and success (p < 0.04), whereas the size of the sheath did not influence the outcome of the UGCT (p = 0.3). CONCLUSION: Our study confirms the effectiveness and safety of UGCT. Routine colour duplex control of the puncture site the day following the removal of the sheath after percutaneous catheterization and UGCT of PAs without delay can increase the success rate of UGCT and minimize the need for surgical repair of PAs.
It has been shown that the incidence of recurrent stenosis following successful percutaneous transluminal coronary angioplasty (PTCA) is correlated with serum Lipoprotein(a) [Lp(a)] levels. The aim of the present study was to examine the influence of Lp(a) on restenosis after primary successful femoropopliteal PTA. One hundred and thirty nine consecutive patients with peripheral arterial occlusive disease (PAOD) and successful femoropopliteal PTA were studied. Follow-up included clinical examination and non-invasive laboratory testing (pulse volume recordings, ankle-brachial arterial pressure measurement) in every patient before and after 1, 3, 6 and 12 months following intervention. Duplex sonography was performed 1 year after PTA. Suspicion of restenosis (> or = 50% diameter reduction) was verified by angiography. Lp(a) was determined using ELISA technique (mg/dl). Twelve months after successful PTA no restenosis was found in 82 patients (59%: group A). The one-year recurrence rate of 41% (group B) was due to significant restenosis in 35 patients (25%) and reocclusion in 22 patients (16%). The corresponding mean values +/- S.E.M. for Lp(a) were as follows: group A, 28 +/- 5.3; group B 59 +/- 11 (P < 0.01). Women showed a higher frequency of recurrences (55%) versus men (30%, P < 0.01) also corresponding with a high Lp(a) level (51.8 +/- 8 versus 32.7 +/- 5; P < 0.05). Furthermore Lp(a) aggravated the well known increased risk for recurrence in multiple stenoses or occlusions of > or = 5 cm in length. There were no significant differences between groups A and B with respect to age, diabetes, hyperlipidaemia, obesity and cigarette smoking. The results support the view that Lp(a) is an independent risk factor for recurrence after PTA in the femoropopliteal area. It might also be a causal basis for the higher incidence of recurrences in female PAOD patients.