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Angioscopic evaluation of thrombus removal by the POSSIS AngioJet thrombectomy catheter.
Coronary angioplasty in a thombotic vein graft is associated with a low success rate and a high risk of periprocedural complications. The aspiration thrombectomy catheter is a new device designed to treat such cases. We report a first angioscopic description of thrombus removal by the AngioJet thrombectomy catheter.
Updating the American College of Rheumatology preliminary classification criteria for systemic sclerosis: addition of severe nailfold capillaroscopy abnormalities markedly increases the sensitivity for limited scleroderma.
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Raynaud's phenomenon and the role of capillaroscopy.
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Vascular endoscopy: useful tool or interesting toy.
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The surgical anatomy of the ansa pectoralis.
Detailed anatomical knowledge of the pectoral nerves is of clinical importance in surgeries as diverse as limb neurotization, mastectomy, orthopedic procedures and operations related to trauma. The brachial plexus of 200 cadavers were examined in an attempt to clarify the normal origins, courses and variations of the nerves with special emphasis on the ansa pectoralis (AP). In 75% the MPN arose from the anterior division of the inferior trunk of the brachial plexus and in 25% it arose from the medial cord. In 40% of specimens, the LPN arose from a single contributing nerve (anterior division of the superior trunk, 11%; anterior division of the middle trunk 18%; lateral cord, 11%). In the remaining 60% of specimens, the LPN arose from the fusion of two rootlets derived variably from the anterior divisions of the superior and middle trunks and the lateral cord. A single AP was found to be present bilaterally in 200 (100%) of the specimens. Classification of the AP was based upon its origin from the upper or lower rootlet of the LPN, the LPN itself, or from the deep branch of the LPN. AP-1 (42%) arose from the deep branch of the LPN; AP-2 (28%) arose directly from the LPN; AP-3 (25%), arose from the lower rootlets of the LPN and rarely, the AP arose from the upper rootlet of the LPN and crossed posterior to the lower rootlet to communicate with the MPN (AP-4, 5%). Irrespective of the aforementioned types, the AP was found to be present, crossing the second segment of the axillary artery in 90% of the specimens. These results could prove useful during the preoperative planning of neurotization and other surgical procedures involving the axilla.
Endovascular stent implantation in the pulmonary arteries of infants and children without the use of a long vascular sheath.
Endovascular stent implantation for pulmonary artery stenosis requires the use of a long, large-bore vascular sheath to insure precise implantation without embolization or malposition. A long vascular sheath may be difficult to position and usage may be associated with vascular compromise and/or hemodynamic embarrassment, especially in infants and small children. We report a new technique for pulmonary artery endovascular stent implantation without the use of a long sheath. From December 2000 to May 2001, 10 patients underwent implantation of 13 Palmaz Corinthian premounted biliary transhepatic stents for pulmonary artery stenosis. Median age was 0.8 years (range, 0.5-18.5) and median weight was 11.8 kg (range, 4.6-65). Patient diagnoses were tetralogy of Fallot (five), double outlet right ventricle (three), branch peripheral pulmonary artery stenosis (two), single ventricle s/p cavopulmonary shunt (one), and truncus arteriosus (one). All Palmaz Corinthian stents were delivered uncovered on Cordis Opta LP balloon catheters via short sheaths (6-7 Fr); super-stiff guidewires were not always necessary. These stents, with a maximal expanded diameter of 12 mm, were placed for peripheral pulmonary artery stenosis as a definitive procedure or at the pulmonary artery bifurcation in patients who were expected to undergo future open heart surgery. The stents were initially implanted on 4, 6, or 8 mm balloon catheters and further expanded if needed. Stents were placed in the right pulmonary artery alone in three patients, left pulmonary artery alone in four patients, and side-by-side stents were implanted simultaneously in three patients. All thirteen stents were implanted successfully in the desired location without stent malposition or embolization. Mean angiographic diameter increased from 2.5 +/- 1.5 to 5.7 +/- 1.4 mm (P < 0.01) and peak systolic ejection gradients decreased from 44 +/- 22 to 14 +/- 11.6 mm Hg (P < 0.01). The uncovered delivery of the premounted Palmaz Corinthian stent allowed for precise and safe endovascular stent implantation without the hemodynamic and technical problems associated with long vascular sheath usage. This technique is useful for the palliation of proximal pulmonary artery stenosis and is effective definitive treatment for peripheral pulmonary artery stenosis in small infants and children.
All that glitters is not gold.
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N-acetylcysteine improves microcirculatory flow during smoking: new effects of an old drug with possible benefits for smokers.
BACKGROUND: Cigarette smoking provokes marked acute changes in the microcirculatory vasculature, including a reduced blood flow velocity. In accordance with the hypothesis that the reduced blood flow is due to an imbalance between pro-oxidants and oxidants, we recently showed that most of the reduction could be reversed by a high dose of vitamin C. HYPOTHESIS: In the present work we tested the hypothesis that N-acetylcysteine, a mucolyticum and an antioxidant, may have an effect on the smoking-induced changes observed by vital capillary microscopy of the nailfold. METHODS: In all, 37 healthy volunteers of both genders and with varied smoking habits were treated with N-acetylcysteine 200 mg t.i.d. for 2 weeks. In vivo investigation of the microcirculation by capillaroscopy was performed before and after treatment. RESULTS: Treatment with N-acetylcysteine significantly reduced the smoking-induced relative decrease in capillary blood flow velocity in a group of volunteers with varied smoking habits (p = 0.0016). The preventive effect was clearly significant in smokers (p = 0.003). CONCLUSION: Treatment with N-acetylcysteine has a positive impact on microcirculatory flow during smoking, particularly in habitual smokers.
Evaluation of serial application of capillaroscopy, photoplethysmography, and dermothermometry in diagnosis and prevention of radiolesions of peripheral microvessels.
This study was performed with the aim of evaluating the justifiability of serial application of nailfold capillaroscopy, digital dermothermometry and digital photoplethysmography in the diagnosis of vascular radiolesions in subjects occupationally exposed to ionizing radiation. Thirty-eight exposed examinees, as well as 30 control persons, were included in the study. In order to establish the condition of the peripheral blood flow, each subject was examined by all the three methods. The results of this work and their statistical evaluation showed the nailfold capillaroscopy and digital dermothermometry to be the most suitable combination of methods for detection of initial changes on the smallest skin blood vessels, subsequent to skin irradiation, while the use of photoplethysmography should be limited to such cases where alterations of digital arterioles are expected.
Human capillaroscopy by light emitting diode epi-illumination.
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Early diagnosis of systemic sclerosis.
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Vasospasmolytic therapy in patients with SSC.
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Predictive value of nailfold capillaroscopy in the diagnosis of connective tissue diseases.
We revised the clinical files of 326 patients who underwent nailfold capillaroscopy. These patients could be subdivided into 4 groups: I: patients with clinical suspicion of connective tissue disease, II: patients with isolated Raynaud's phenomenon, III: patients with existing connective tissue disease, IV: patients with acrocyanosis, chronic pernio or related disorders. The presence of megacapillaries was noted. The sensitivity of their presence for the various categories of connective tissue disease was as follows: systemic sclerosis (n = 11): 100%, CREST (n = 15): 73%, MCTD (n = 9): 56%, dermatomyositis (n = 7): 86%. Nineteen patients with megacapillaries had no final diagnosis of connective tissue disease (specificity 93.3%). The positive predictive value of the presence of megacapillaries for a scleroderma spectrum disorder (SSD) was 63.5% and the negative predictive value of a normal capillaroscopy 96.7%. We conclude that nailfold capillaroscopy can be advised to rule out SSD's.
[Assessment of diabetic alterations of microcirculation by means of capillaroscopy and laser-Doppler anemometry].
BACKGROUND: Only minor changes of skin capillary morphology have been described in diabetic patients by means of capillaroscopy, whereas cutaneous microvascular dysfunction is well known. We examined correlations between functional and morphological abnormalities of the capillaries in Type 1 and 2 diabetic patients and the influence of diabetes duration on capillary morphology. PATIENTS AND METHODS: Density, diameters and morphology of nailfold capillaries were investigated in diabetic patients, 16 Type 1 and 19 Type 2, and compared to age- and sex-matched control groups. Capillary blood cell velocities (CBV) during rest and after 3-minute arterial occlusion were measured in the dorsal middle phalangeal area of the left ring finger by means of laser Doppler anemometry. RESULTS: Capillary density, width and arterial limb diameter were similar in Type 1 and 2 diabetic patients compared to their controls. Capillary diameters of the apical part and the venous limb were enlarged in the combined analysis of Type 1 and 2 diabetic patients compared to the control group (apex: 19.2 +/- 0.6 microns vs 17.4 +/- 0.6 microns, p = 0.0243; venous limb: 17.3 +/- 0.5 microns vs 15.9 +/- 0.4 microns, p = 0.0238). Tortuous capillaries were more often observed in Type 1 (n = 13 vs n = 7, p = 0.028) and 2 diabetic patients (n = 16 vs n = 9, p = 0.019) than in controls. In Type 1 diabetic patients an inverse correlation (r = -0.52; p = 0.019) was found between capillary density and resting CBV. In Type 2 diabetic patients capillary apex diameter correlated positively with peak CBV (r = 0.49; p = 0.017). Disease duration correlated inversely with arterial limb diameter (r = -0.48; p = 0.020) and width of the capillaries (r = -0.48; p = 0.018) in Type 2 diabetic patients. CONCLUSION: Tortuous and dilated capillaries, indicating microangiopathy, were found in the skin of diabetic patients by means of capillaroscopy. Using laser Doppler anemometry it is possible to assess impairment of postocclusive reactive hyperemia, due to diabetic microvascular dysfunction, in single capillaries. Correlations between morphological and functional microcirculatory alterations in diabetes may be explained by hemodynamic changes, depending on diabetes duration.
[Vulnerable plaque -- vulnerable vessel -- vulnerable patient. Plaques prone to rupture in atheroma/fibroatheroma].
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[Noninvasive methods in the diagnosis of macro- and microangiopathy of peripherial and carotid arteries].
PURPOSE: Indications and diagnostic value of the most important noninvasive procedures for the diagnosis of peripheral arterial disease and diseases of the supraaortic arteries are reviewed in this article with particular emphasis on cardiologic questions. PERIPHERAL ARTERIAL DISEASE: As compared to coronary artery disease, peripheral arterial disease has long been addressed as being negligible in number and importance, a view that had to be reassessed in recent years. The prevalence of claudication and critical leg ischemia has increased. Earlier diagnosis and specific therapeutic regimens will be able to prevent or at least slow progression of the disease and, thereby, major amputation. The patient's history and physical examination in addition to measurement of the ankle-brachial index (ABI; determined by dividing the systolic pressure measured by Doppler ultrasonography of the A. dorsalis pedis or A. tibialis posterior by that of the A. brachialis) usually allows for the diagnosis of peripheral arterial disease (ABI < 0.9). If in doubt (ABI > 0.9, but presence of typical claudication), a treadmill test or additional tests such as pressure-pulse recording (mechanical oscillography), toe pressure measurements, or duplex ultrasonography should be performed. When peripheral arterial disease has been diagnosed, duplex ultrasonography or treadmill testing aids in planning additional diagnostic procedures and the adequate therapeutic regimen. Transcutaneous oxymetry is of prognostic value in assessing the tendency of wound healing in distal limb ulceration and can distinguish between critical limb ischemia and complicated claudication. Thermography is used to document functional and organic peripheral arterial occlusions and capillaroscopy to directly view nail fold capillaries in order to distinguish between primary and secondary Raynaud's phenomenon. Noninvasive radiologic techniques in the diagnosis of peripheral arterial disease are also discussed in this journal. SUPRAAORTIC ARTERIES: Noninvasive diagnostic procedures in assessing disease of the supraaortic arteries include history-taking, physical examination, continuous-wave-(cw-)Doppler and color-coded ultrasonography. Cw-Doppler ultrasonography is still widely used and sufficient in diagnosing moderate to severe stenosis or occlusion of the carotid artery. B-mode and color-coded ultrasonography has several advantages over cw-Doppler ultrasonography through direct visualization of the vascular membrane, perivascular structures, and intravascular blood flow. Carotid stenosis < 50% and plaque morphology can be assessed, inflammatory processes, aneurysms, and dissections diagnosed. Increase in intima-media thickness and echolucent plaques are associated with cerebral ischemic events and can be diagnosed via duplex sonography. These findings have great implications in the consultation of patients with atherogenic risk factors.
[Conventional aortic surgery after endovascular aortic reconstruction].
INTRODUCTION: Endovascular therapy of aortic aneurysms is an attractive alternative to conventional aortic surgery. A number of patients, however, will fail endovascular therapy and require open surgical repair. METHODS: We report our experience with conversion to open aortic repair. Of 306 patients given endovascular therapy for an infrarenal aortic aneurysm, 30 (9.8%) required conversion to conventional repair. RESULTS: Thirteen patients (43.3%) suffered complications, 3 (10%) of which were fatal. Conversion to open aortic repair after endovascular therapy is technically more demanding than primary open repair, particularly because of clamp techniques and stent-extraction. CONCLUSIONS: Emergent conversion operations, especially when preceded by significant retroperitoneal bleeding from vascular tears due to endovascular manipulations are complicated by significant morbidity and mortality.