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PubMed1988

Emergency intracranial thromboendarterectomy for acute middle cerebral artery embolus.

Clinical application of microvascular techniques in emergency intracranial thromboembolectomy of middle cerebral artery bifurcation subsequent to angiography is presented. Blood flow was re-established with 5-7 hours of the onset of the focal cerebral ischemic symptoms. Review of the literature supports a role for acute intracranial embolectomy in a selected group of patients in the absence of more effective medical therapy.

Acute Disease↗
PubMed1999

Lower limb ischemia: phase 1 results of salvage perfusion.

Revascularization of an ischemic lower extremity is associated with high morbidity (20-30%) and perioperative mortality (10-20%) regardless of the mode of intervention, surgical or thrombolytic, considered to be due to polymorphonuclear (PMN) activation and mediator release. In this study, the safety and feasibility of cell-free extracorporeal perfusion of the limb with a solution designed to minimize both local and systemic injury was tested. Methods. Patients with severe limb ischemia (sensory/motor loss, rest pain/gangrene) were studied prospectively by random assignment into the treatment arm (n = 14) or control arm (n = 21). Surgical management consisted of restorative procedure, thrombectomy or embolectomy (n = 21), or reconstruction (n = 14). Reperfusion of the ischemic limb was achieved with hypertonic, hyperoncotic perfusate containing anti-oxidants delivered via the arterial tree (mean volume 1835 +/- 824 ml) with initial venous drainage (mean volume 775 +/- 263 ml) in the restorative group. Means were compared by paired t test. Results. No adverse systemic effects were detected after limb perfusion (electrolytes, coagulation, platelet function, CBC). Rapid lactate wash-out was observed within 30 min of perfusion (preperfusion 3.2 +/- 4.1 mM, 30 min postperfusion 0.7 +/- 0.71 mM, P < 0.01). Blunting of PMN activation was shown by chemiluminescence (CL) analysis (preischemic CL: 0.68 +/- 0.2; 30 min CL: 0.47 +/- 0. 2; P < 0.013). F2-isoprostanes, a marker of free radical-mediated systemic lipid peroxidation, were significantly reduced in patients treated with study perfusion method (70.55 +/- 39.54 versus control 194.38 +/- 25.24, P < 0.005). Mortality with treatment was 0/14 versus 5/21 in the control. Complication frequency: MI 0/14 vs 3/21; renal 0/14 vs 1/21; leg edema 1/14 vs 5/21; amputations 2/14 vs 1/21. Conclusion. Modification of limb perfusion in patients with severe limb ischemia, using our simple and rapid (15-20 min) method provides beneficial systemic effects.

Cohort Studies↗
PubMed1979

Pentothal protection for delay cerebral revascularization.

Thiopentone (20 mg/kg/bolus and 20 mg/kg/three hours) was effective in preventing infarction in five dogs with six hours of middle cerebral occlusion. Nine control animals sustained massive to large infarctions. Utilizing this regime therapeutic blood levels were rapidly attained for over 12 hours without side effects. From the experimental and human experience with focal cerebral ischaemia, there appears to be a finite grace period in which cerebral revascularization can be undertaken. In canine and primate models this time has been about five hours, following which the infarction process may not be reversible (Sundt et al. 1977, Laha et al. 1978). Seeking to prolong this grace period, thiopentone was selected as an ideal drug for this purpose, and its effect on the revascularized canine middle cerebral distribution was evaluated at six hours following embolectomy.

Animals↗
PubMed1994

Severe complications following thrombolytic therapy of an acute thrombosis of a prosthetic mitral valve.

Thrombosis of prosthetic cardiac valves is a rare but potentially lethal complication. As emergency surgical intervention of thrombotic prosthetic cardiac valves is correlated with high mortality, fibrinolytic therapy has been recently recommended as a therapy with high efficacy and no severe side effects. We report on a patient with thrombosis of a prosthetic mitral valve who developed severe embolic complications following the administration of the thrombolytic agent. On admission the patient showed signs of incipient cardiogenic shock. The diagnosis of thrombotic obstruction of the prosthetic mitral valve was confirmed by transesophageal echocardiography. The effective valve area was 0.41 cm2. Pulmonary arterial blood pressure and wedge pressure were significantly elevated. A fibrinolytic therapy with recombinant tissue-type plasminogen activator according to the Neuhaus scheme was attempted. Within 60 min after start of treatment the effective valve area increased (1.41 cm2), and the pulmonary capillary wedge pressure decreased. However, peripheral and cerebral embolism occurred. Occlusion of the right brachial and right femoral artery was ascertained by Doppler ultrasound. Embolism into the right leg made an embolectomy with a Fogarty catheter necessary. Computed tomography revealed two lesions located in the occipital and left temporal area of the brain. Correlated with the lesions evaluated in computed tomography, right hemiplegia and complete aphasia was observed. The neurological status of the patient has only slightly improved to the present. To our knowledge no severe persistent neurological deficits following thrombolytic therapy have been reported. We therefore assume that the risk of severe neurological complications is underestimated.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1993

Efficacy and tolerance of recombinant tissue-type plasminogen activator in patients with thrombotic or embolic occlusions of leg-arteries.

The efficacy and safety of recombinant tissue-type plasminogen activator (rt-PA) was evaluated in 46 patients with thromboembolic arterial occlusions in leg arteries. rt-PA was given over 1-4 h with a maximum dose of 18 mg. The effect of rt-PA treatment was determined as patency of the occluded arteries in 44 different patients 14 days after treatment. In 41 patients at least one artery was recanalized (93%) by rt-PA, and in almost half of these patients (48%) no residual stenosis were detected after the lytic treatment. A slight residual stenosis was detected in 29% of the patients and a severe residual stenosis in 21%. An additional treatment with percutaneous transluminal angioplasty was performed in 23 of the 44 patients and successful in 21 (91%). In 8 patients an addition catheter-embolectomy was performed. No difference in patency rate was detected between patients with thrombotic and those with embolic occlusions. The age of the occlusion influenced the patency rate; occlusions under the age of 5 weeks showed a patency rate of 96% compared to 82% in older occlusions. The length of the occlusion did not have any influence on the outcome of the rt-PA treatment. From the results of this open study we conclude that a dose of up to 18 mg of rt-PA is both safe and effective in the treatment of thromboembolic occlusions in leg arteries.

Adult↗
PubMed1986

Unresolved major pulmonary embolism: importance of follow-up lung scan in diagnosis.

Unresolved major pulmonary embolism (UMPE) is an uncommon condition which causes pulmonary hypertension, cor pulmonale and death. An accurate and prompt diagnosis of UMPE is very important in the management of such patients with pulmonary embolectomy. Follow-up lung scans can lead to earlier diagnosis of UMPE, especially in patients who have a history of acute pulmonary embolism and present with pulmonary hypertension, respiratory insufficiency and cor pulmonale. We report a case of UMPE strongly suggested by follow-up lung scans and subsequently confirmed by pulmonary angiography and postmortem examination.

Adult↗
PubMed1984

Therapeutic approach to acute pulmonary embolism.

Many therapeutic aspects of venous thromboembolism continue to generate controversy so that the general therapeutic guidelines given below are only indicative. The first step is the diagnosis of venous thromboembolism; this is done in the vast majority of patients by visualization of blood clots using either pulmonary angiography or phlebography. The second step is to arrest the thrombotic process; the best means of doing this is to administer IV heparin. In the case of contra-indication or documented inefficacy of heparin therapy, the only therapeutic solution is to interrupt the inferior vena cava either with a clip, an umbrella or a filter. The blood clot lysis, which represents the third step, is effected by the natural fibrinolytic system. Thrombolytics , administered as a bolus of urokinase (15000 CTA U/kg), are indicated in cases of life-threatening pulmonary emboli, i.e. those with a pulmonary vascular obstruction of more than 50% and with hypotension, shock, or acute right ventricular failure. The use of thrombolytics is more questionable when they are administered to improve the quality of vascular patency. The only indication for pulmonary embolectomy is a contra-indication or inefficacy of thrombolytics . Due to the diagnostic and therapeutic difficulties, the first and most important part of the treatment of pulmonary emboli must be the broad application of prophylaxis treatment in patients with a high risk of venous thromboembolism.

Acute Disease↗
PubMed1982

Left atrial myxoma presenting with synchronous carotid and femoral embolism.

Synchronous embolism of the right femoral and the left internal carotid arteries, occurring in a 39-year-old teacher upon physical effort, was found to be due to a left atrial myxoma. Clinical findings, electrocardiogram and chest radiographs had suggested myocarditis. The patient died of cerebral infarction. In cases of suspected myocarditis, left atrial myxoma has to be considered in the differential diagnosis. Histological examination is recommended of any material obtained by embolectomy.

Adult↗
PubMed1977

En face organ cultures of rabbit aortic segments after a single dilatation trauma in vivo. A new model in the study of endothelial regeneration.

Following an in vivo lesion of the rabbit thoracic aorta, endothelial regeneration was studied in silver-stained specimens from en face organ cultures of aortic segments with and without intercostal arteries. The in vivo lesion had been inflicted by an embolectomy catheter. Our results confirmed that endothelium regenerates from preexisting endothelium around the mounths of the intercostal arteries. A conspicuous observation was the orientation pattern of endothelial cells during regeneration. Transmission electron microscopy suggests that the cell cytoskeleton plays a role in the regulation of regeneration. The organ culture technique described, complementary to in vivo and in vitro investigations with cell cultures, seems to be a valuable tool in further investigations on factors involved in the repair of arterial tissue.

Animals↗
PubMed1984

Histological findings in sutured and fibrin-glued microvascular anastomosis.

A new method of microvascular anastomosis is presented. A sufficient sutureless telescoping anastomosis was achieved using fibrin adhesive (Tissucol, Immuno GmbH, Heidelberg, FRG) and a Fogarty embolectomy catheter (American Hospital Supply, Deutschland GmbH, Munich, FRG) as an internal splint in the abdominal aorta of Sprague-Dawley rats. The main advantage of this technique is its short application time. Histological examinations mostly showed accelerated healing compared with sutured anastomosis.

Animals↗
PubMedDate not supplied

Local fibrinolysis for superior mesenteric artery thromboembolism.

A 66-year-old man with atrial fibrillation was referred soon after developing left lower limb and abdominal pain with rectal bleeding. An immediate flush aortogram showed embolic occlusion of the left distal superficial femoral artery and superior mesenteric artery (SMA), 3 cm from its ostium. Recombinant tissue plasminogen activator (rtPA) 40 mg was selectively instilled in the SMA in two boluses. Abdominal symptoms resolved within 48 h, and complete recanalization of the SMA was shown on angiography. Exploratory laparotomy after 72 h showed a normal small bowel and right colon, and was completed by femoropopliteal embolectomy. Six months later, the patient remained asymptomatic.

Aged↗
PubMed1983

Repair in arterial tissue. Demonstration of fibronectin in the normal and healing rabbit thoracic aorta by the indirect immunoperoxidase technique.

Immunoperoxidase staining for fibronectin in ethanol- and formaldehyde-fixed, normal and healing arterial tissue is presented. Proteolytic digestion of sections fixed in formaldehyde increased the staining intensity for fibronectin in media from normal thoracic aorta and in neo-intima covered with endothelium, and had a similar effect on media from thoracic aortae with an embolectomy catheter lesion. The staining reaction for fibronectin in formaldehyde-fixed neo-intima covered with aortic smooth muscle cells was strong and almost independent of proteolytic digestion. In re-endothelialized neo-intima with a high content of proteoglycans a masking effect was observed, probably depending on poor access of immunoglobulins to fibronectin. The masking effect observed in non-re-endothelialized neo-intima with a low content of proteoglycans was much weaker. The correlation between the choice of fixative and unmasking of antigenic determinants by proteases is discussed.

Animals↗
PubMed1987

Injury and repair of smaller muscular and elastic arteries. A light microscopical study on the different healing patterns of rabbit femoral and carotid arteries following dilatation injuries by a balloon catheter.

26 rabbits of the Danish country strain were subjected to mechanical dilatation injury of the left femoral and carotid arteries with Fogarty's embolectomy catheters F2 and F3 respectively. The rabbits were killed 2, 7, 14 and 28 days after the dilatation injury and the arteries examined histologically. Initially both of the arteries exhibited necrosis of the media and infiltration of the vessel wall with neutrophils and mononuclear cells. From day 7, intimal thickening was observed in both types of arteries, progressing in thickness during the later stages. However, thrombosis occurred in the majority of the carotid arteries, whereas this was only infrequently seen in the femoral arteries. In all of the dilated arteries, the elastic laminas were stretched or fragmented and never regained their normal appearance. In the carotid artery, giant cells accumulated around the fragmented elastin and calcified areas, located primarily at the intima-medial border. These changes were never observed in the femoral artery. At the twenty-eight days stage, proliferation of the smooth muscle cells more or less led to restitution of the media in the femoral artery, whereas the carotid artery showed medial restitution only to a lesser extent. The similarities between the injured carotid artery and human temporal arteritis, and the utility of the model as an animal model for the study of temporal arteritis are underlined.

Angioplasty, Balloon↗
PubMed1986

[Prevention of pulmonary embolism using a vena cava filter and cava clip].

Surgical prophylaxis of pulmonary embolism by implantation of Vena-cava-filter (Greenfield) or Vena cava clip (Adams de Weese) was performed in 24 patients. The following indications were used: Recurrent pulmonary embolism under adequate anticoagulation, Pulmonary embolism in cases of contraindications to anticoagulation, Floating thrombus occurring late following deep vein thrombosis, After pulmonary embolectomy. In a retrospective study we recognized 0% recurrent pulmonary embolism, a vena cava occlusion rate of 4% and no clinically relevant signs of bilateral venous stasis in the lower limbs.

Adolescent↗
PubMed1987

[Differential indications for surgical and conservative internal medicine procedures in the treatment of acute ischemia of the leg].

Re-opening of the main arterial pathway is the most efficient method for treatment of arterial occlusive disease in stage III and IV. In addition to surgical thromb-embolectomy catheter procedures such as percutaneous transluminal angioplasty, catheter lysis and catheter extraction of fresh clots may give satisfactory results. The following methods are indicated in acute cases: catheter procedures for occlusions of the popliteal trifurcation and profound femoral artery, segmental occlusions of the superficial femoral artery, femoro-popliteal occlusions with impaired run-off, recurrent occlusions after desobliteration with both surgical methods, occlusions of lower arm arteries; surgical thrombectomy for occlusions of the aortic bifurcation, the iliac arteries, the femoral bifurcation, for femoro-popliteal aneurysms and for occlusions of the subclavian and axillary artery. Both procedures do not exclude each other and may be combined according to the relevant indications.

Angioplasty, Balloon↗
PubMed1986

[Transluminal dilatation and other nonsurgical catheter technics in the treatment of renovascular hypertension].

The development of percutaneous transluminal techniques has brought up new possibilities for causative treatment of renovascular hypertension. In renal artery stenosis transluminal angioplasty is meanwhile routinely applied; experience with angioplasty to date exceeds by far the number of 1000 published cases. Technical success is obtained in more than 90%. The clinical success in the therapy of reno-vascular hypertension is approximately 76% over all with nearly equal cure and improvement rates. In fibromuscular stenosis clinical success has been obtained in 95% with a cure rate of 56% and improval in 39%. The cure rate is particularly low in patients with atherosclerotic stenosis with 19%, however in 60% improvement has been obtained, resulting in clinical benefit in 79%. Results obtained by surgery seem to be superior to those of dilatation, especially with regard to cure rates. However, the differences are minor and are compensated by the evident advantages of transluminal dilatation, especially its easy application and lower risk. Thus, 8 years after its introduction in nephrology, transluminal dilatation is the therapy of choice in renal artery stenosis. Other nonoperative interventional techniques, including transcatheter aspiration and embolectomy, intraarterial thrombolysis, embolisation and modified angioplasty provided valuable alternatives to usual surgical therapy. However, experience with some of these procedures is still limited. The complication rate of transluminal angioplasty of 10-20%, necessitating surgery in nearly 5%, prohibits its uncritical use.

Angioplasty, Balloon↗
PubMed1983

Direct microsurgical intra-arterial procedures on ICA and MCA.

In ten patients operated on by the senior author, arteriotomy and reconstruction of the vessel wall with interrupted sutures were performed. Four patients underwent resection of an aneurysm, three thrombectomy, and one embolectomy, while in two patients an atherosclerotic plaque with thrombus was removed. Operation was undertaken to create normal vessel volume and restore and maintain adequate regional blood flow. These objectives were attained completely in seven cases and only partially in two cases, whereas in one patient we failed to meet the above requirements.

Adolescent↗
PubMed1991

Ultrasound guided therapeutic catheters: recent developments and clinical results.

The increasing use of intravascular ultrasound technology by clinicians is providing detailed and immediate information about the results of interventions, and this is stimulating the development of new catheters that use ultrasound imaging to control therapy in real time. Cold and thermal balloon angioplasty, atherectomy, embolectomy, laser ablation and rotational recanalization are a few of the interesting capabilities now being added to ultrasound catheters. We report on the development and characteristics of some of these devices and attempt to assess their potential to precisely direct therapy.

Angioplasty, Balloon↗