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PubMed2000

Beta-adrenergic responses are significantly enhanced in rat carotid artery with intimal hyperplasia.

The objective of the present study was to investigate the influence of balloon injury and subsequent neointima formation in the rat carotid artery on the beta-adrenoceptor function. Rat left common carotid artery was subjected to balloon injury with an arterial embolectomy catheter; the contralateral artery was sham-operated. Immediately, and at 2, 8 and 16 weeks post-injury, both the injured and the sham-operated carotid arteries were isolated and mounted in an isometric wire-myograph set-up. Subsequently, concentration-response curves (CRCs) were constructed for the beta-adrenoceptor agonist isoprenaline after precontraction with the thromboxane A2 (TP)-receptor agonist U46619 (30 nM) of the injured and sham-operated artery preparations. To evaluate the involvement of the beta1- and the beta2-adrenoceptor subtypes, CRCs were constructed in the presence of CGP 20712A (0.1 nM, a beta1-adrenoceptor-selective antagonist) and ICI 118,551 (10 nM, a beta2-adrenoceptor-selective antagonist). L-NAME (100 microM) and indomethacine (10 microM) were used to evaluate the influence of nitric oxide (NO) or prostanoids, respectively. Immediately post-injury, isoprenaline-induced vasorelaxation was impaired in the injured carotid artery preparations: Emax=19.6 +/- 2.2% vs. 64.0 +/- 4.6%, injured vs. sham, n=8, P<0.05. However, from 2 weeks post-injury onwards, this response appeared enhanced in the injured preparations: Emax, 2 weeks= 86.4 +/- 2.2% vs. 49.7 +/- 5.7%, injured vs. sham, n=5, P<0.05. In addition, the sensitivity for isoprenaline was increased in these preparations: pD2, 2 weeks=7.48 +/- 0.08 vs. 6.88 +/- 0.10, injured vs. sham, n=5, P<0.05. The beta-adrenoceptor population in both types of preparations consisted mainly of the beta2-adrenoceptor subtype, although at 8 and 16 weeks post-injury, the beta1-adrenoceptor subtype appeared to be present as well in the injured artery preparations. Inhibition of NO synthesis led to significant decreases of beta-adrenoceptor-mediated vasorelaxation both in injured and in sham-operated artery preparations for all time points, except at 16 weeks. Cyclo-oxygenase inhibition had no influence on isoprenaline-induced vasorelaxation in injured and sham-operated preparations. From this, it is concluded that beta-adrenoceptor-mediated vasorelaxation in rat carotid artery is partially NO-dependent and occurs mainly via activation of the beta2-adrenoceptor subtype. Balloon injury and subsequent neointima formation in the rat carotid artery lead initially to an impairment, but subsequently to an enhancement of the beta-adrenoceptor-mediated vasorelaxation. The impairment is attributable to the removal of endothelium, whereas the enhanced beta-adrenoceptor-mediated function may be related to the occurrence of an NO system in the neointimal smooth muscle cells.

Adrenergic beta-Agonists↗
PubMed2006

Reperfusion injury following cerebral ischemia: pathophysiology, MR imaging, and potential therapies.

INTRODUCTION: Restoration of blood flow following ischemic stroke can be achieved by means of thrombolysis or mechanical recanalization. However, for some patients, reperfusion may exacerbate the injury initially caused by ischemia, producing a so-called "cerebral reperfusion injury". Multiple pathological processes are involved in this injury, including leukocyte infiltration, platelet and complement activation, postischemic hyperperfusion, and breakdown of the blood-brain barrier. METHODS/RESULTS AND CONCLUSIONS: Magnetic resonance imaging (MRI) can provide extensive information on this process of injury, and may have a role in the future in stratifying patients' risk for reperfusion injury following recanalization. Moreover, different MRI modalities can be used to investigate the various mechanisms of reperfusion injury. Antileukocyte antibodies, brain cooling and conditioned blood reperfusion are potential therapeutic strategies for lessening or eliminating reperfusion injury, and interventionalists may play a role in the future in using some of these therapies in combination with thrombolysis or embolectomy. The present review summarizes the mechanisms of reperfusion injury and focuses on the way each of those mechanisms can be evaluated by different MRI modalities. The potential therapeutic strategies are also discussed.

Brain Ischemia↗
PubMedDate not supplied

Successful thrombolytic therapy of pulmonary embolism associated with urosepsis in an infant.

Childhood pulmonary embolism (PE) is a rare but serious condition marked by hypoxemia, shock, right-sided heart failure, and significant risk for fatality. Recommended treatment options include surgical embolectomy, anticoagulation, and thrombolysis. This report describes the successful use of recombinant tissue plasminogen activator to treat PE associated with urosepsis in a 34-day-old infant and reverse severe hemodynamic compromise. Diagnosis of proximal PE and monitoring its treatment were successfully achieved by echocardiography.

Echocardiography↗
PubMed2003

Vascular thoracic outlet syndrome.

The surgical treatment of 30 cases of vascular thoracic outlet syndrome (TOS) in 25 patients is presented. Patients included 17 women and 8 men with average age of 26.1 years. The causes of compression were cervical rib ( n = 16), soft tissue anomalies ( n = 12), and scar tissue after clavicle fracture ( n = 2). Ten subclavian artery aneurysms containing intraluminal thrombus as well as one subclavian artery occlusion were found. All such cases had multiple distal arterial embolization. Presenting features of cases with arterial TOS included: hand ischemia ( n = 11), transient ischemic attack (TIA) ( n = 1), and claudication or vasomotor phenomena during the arm hyperabduction ( n = 11). Two patients with venous TOS developed hand edema during arm hyperabduction, and five other patients had axillary-subclavian venous thrombosis. In all cases decompressive procedures using a combined supraclavicular and infraclavicular approach were performed. Decompression was achieved by cervical rib excision ( n = 12), combined cervical and first rib excision ( n = 4), and first rib excision ( n = 14). In all cases division of all soft tissue elements was also accomplished. Associated vascular procedures included resection and replacement of 10 subclavian artery aneurysms, one subclavian-axillary and one axillary-brachial bypass, as well as nine brachial embolectomies. All five cases with axillary-subclavian vein thrombosis before decompression were treated with anticoagulant therapy. The mean follow-up period was 3 years and 2 months (range 1 to 6 years). Two pleural entry injuries and two transient brachial plexus injuries were noted. All reconstructed arteries were patent during the follow-up period. Complete resolution of symptoms with a return to full activity was noticed in all cases with arterial TOS and in two cases with venous TOS without axillary-subclavian vein thrombosis. In cases with axillary-subclavian vein thrombosis relief of symptoms was mild, and there were limitations on daily activity. Vascular TOS is seen less frequently than the neurogenic form; however, in most cases it requires surgical treatment. We prefer a combined supraclavicular and infraclavicular approach because it offers complete exposure of the subclavian artery, cervical and first ribs, and all soft tissue anomalies.

Adult↗
PubMedDate not supplied

Successful percutaneous transluminal angioplasty and stenting in acute mesenteric ischemia.

Acute mesenteric ischemia (AMI) is a life-threatening emergency. The complications are high by the time of diagnosis in most cases and therefore only few data on primary percutaneous intervention with percutaneous transluminal angioplasty (PTA) and stenting in AMI are available. We present the case of an 84-year-old woman who presented to our emergency department complaining of an acute worsening of pre-existing abdominal periumbilical pain, nausea, vomiting, and diarrhea. She had previously undergone percutaneous transluminal embolectomy for an acute occlusion of the left common femoral artery. Due to suspicion of intestinal infarction, conventional angiography of the aorta and the superior mesenteric artery (SMA) was performed and confirmed a proximal occlusion of the SMA. Percutaneous SMA recanalization with balloon dilation and subsequent stent implantation was carried out successfully. The abdominal symptoms subsided after this procedure. In AMI that is diagnosed early, endovascular stenting should be considered as an alternative treatment to the surgical approach that avoids the need for surgical bowel resection.

Acute Disease↗
PubMedDate not supplied

The Günther temporary inferior vena cava filter for short-term protection against pulmonary embolism.

PURPOSE: To evaluate clinically the Günther temporary inferior vena cava (IVC) filter. METHODS: Eleven IVC filters were placed in 10 patients. Indications for filter placement were surgical pulmonary embolectomy in seven patients, pulmonary embolism in two patients, and free-floating iliofemoral thrombus in one patient. Eight filters were inserted from the right femoral approach, three filters from the left. Follow-up was by plain abdominal radiographs, cavography, and duplex ultrasound (US). Eight patients received systemic heparinization. Follow-up, during 4-60 months after filter removal was by clinical assessment, and imaging of the lungs was performed when pulmonary embolism (PE) was suspected. Patients received anticoagulation therapy for at least 6 months. RESULTS: Ten filters were removed without complications 7-14 days (mean 10 days) after placement. One restless patient pulled the filter back into the common femoral vein, and a permanent filter was placed. In two patients a permanent filter was placed prior to removal. One patient developed sepsis, and one an infection at the insertion site. Clinically no recurrent PE developed with the filter in place or during removal. One patient had recurrent PE 7 months after filter removal. CONCLUSION: The Günther temporary IVC filter can be safely placed for short-term protection against PE. The use of this filter is not appropriate in agitated or immunocompromised patients.

Adult↗
PubMed2003

Implantation of the Corinthian IQ stent into the femoropopliteal arteries using 6-F introducer sheaths in antegrade and crossover procedures: midterm results.

The aim of this study was to evaluate the technical performance of the implantation of the Corinthian IQ stent into the femoropopliteal arteries using 6-F introducer sheaths. Thirty-three lesions (24 stenoses, 9 occlusions) in 32 patients (mean age 67 years) were stented. Selective stent implantation was performed after unsatisfactory percutaneous transluminal angioplasty result with an antegrade access in 21 patients and through a crossover sheath in 11 patients. A total of 36 stents were implanted. Stent delivery was successful in all cases (stent diameter 5 or 6 mm, stent length 11-38 mm). In none of the cases was stent dislodgement from the balloon observed. Stent placement was optimal without residual stenosis in 30 cases. In 1 case the stent was chosen too short requiring implantation of a second stent. In 1 patient distal embolization was observed which was treated with catheter embolectomy. Nine-month primary and secondary patency rates were 79+/-8.7 and 86+/-7.7%, respectively. Implantation of the Corinthian IQ stent into the femoropopliteal arteries using 6-F introducer sheaths is safe in antegrade and crossover procedures.

Aged↗
PubMed2002

Native valve endocarditis due to Pichia ohmeri.

Candida species can cause clinical manifestations in various organs of the cardiovascular system, i.e., the pericardium, myocardium, and endocardium, with endocarditis being the best-known clinical entity. Endocarditis is seen primarily in intravenous drug users and in individuals with damaged native valves, especially in congenital heart disease or rheumatic valvular diseases, and in prosthetic heart valves. The authors present a case of Pichia ohmeri endocarditis in an intravenous drug user, with an unusual presentation form. This is a case of a 42-year-old man, an intravenous heroin user, who was admitted to our Vascular Surgery Department because of fever and acute serious ischemia of the left inferior limb. He presented with fever (39 degrees C), a pale and cold left limb, absence of the left popliteal pulse, and a pansystolic murmur at the cardiac apex. The transthoracic echocardiogram showed a large vegetation on the anterior leaflet of the mitral valve and severe mitral regurgitation with good left ventricular systolic function. Empirical antibiotic therapy was started. Six days after admission, embolectomy was performed with partial clinical recovery. Three blood cultures and the embolus showed a teleomorphic form of Candida guilliermondii - Pichia ohmeri. Therapy with intravenous liposomal amphotericin B, fluocitosin, imipenem, and aztreonam was started. Two weeks later, his clinical condition deteriorated with acute heart failure refractory to medical therapy, mandating mechanical ventilation and high-dose vasopressor and inotropic amine support. He underwent urgent mitral valve replacement with a biologic prosthetic valve. Rapid stabilization of the cardiac status occurred, but ischemic limb lesions required further vascular interventions.

Adult↗
PubMed2002

History of cardiac surgery in Germany--in consideration of her relation to the German Cardiac Society.

As late as the end of World War II (1945), cardiac surgery did not play a clinical role worldwide. Successful cardiac operations were singular events often caused by unexpected circumstances. In contrast, the first successful suture of a cardiac stab wound by Ludwig Rehn (1896 in Frankfurt am Main) followed after experimental investigation of this topic in the laboratory. With a certain justification, this event can be mentioned as the beginning of clinical cardiac surgery. Operative procedures in patients with constrictive pericarditis followed, at that time, the ideas of Ludolf Brauer (precordial pericardiolysis) and were developed to perfection by Viktor Schmieden (subtotal pericardiectomy) during the 1920s. The first successful pulmonary embolectomy was performed in 1924 by Martin Kirschner; up to this date the sometimes used method of Friedrich Trendelenburg, already described in 1908, remained without success. The first successful operation of a ventricular aneurysm by Ferdinand Sauerbruch (1931) and the first successful closure of a patent duct (Botalli) by Emil Karl Frey (1938) occurred during operations undertaken under the circumstances of a preoperatively incorrect diagnosis. The results of the important experimental work of Ernst Jeger (monography 1913) and the first catheterization of the human heart by Werner Forssmann (1931) were not noticed by the surgical community at that time. In contrast to the time before World War II, in which German surgery was at the forefront, after the war there was a commanding need to approach the scientific and clinical level that meanwhile had been developed in the western countries, while there had been a standstill in Germany caused by its isolation since 1933 and the war since 1939. Surgeons in western Europe, the United States of America, and in Canada proved to be real friends. After one to two decades, the international clinical and scientific standard could be reached at some sites. A widespread clinical care for all patients became possible only in the late 1980s. This development was hampered even more in the eastern parts of the country. Above-average efforts there, equalized the degree of clinical care in a few years. The co-operation between the German Cardiac Society (founded 1927) and the German Society for Thoracic and Cardiovascular Surgery (founded 1971) was of great benefit for this satisfying development.

Cardiology↗
PubMed2003

[Atypical Leriche syndrome].

A 73-year old woman presented with mild paraparesis and hypesthesia of the legs. Furthermore, she complained dizziness, fainting and dyspnea. There was a history of peripheral artery disease, diabetes mellitus, arterial hypertension and chronic atrial fibrillation. Five years ago she had breast cancer with removal of the left mamma and additional radiation therapy. Cardiac catheterization at that time demonstrated no significant coronary stenoses. A contrast-enhanced CT-scan excluded lumbal spinal metastases. Instead, a subtotal occlusion of the abdominal aorta was noticed, but was initially interpreted as a chronic thrombosis because there were no typical symptoms and only moderate pain. About 24 hours later the patient developed an acute ischemic syndrome of the legs with progressive paraparesis, cold and pale legs in combination with acidosis and hyperventilation. Color-coded duplex ultrasound showed only a small turbulent flow in the ilial arteries, highly suspicious of a complete occlusion of the distal aorta. Angiography revealed an acute total occlusion of the infrarenal aorta without collaterals. During surgical intervention, complete obstruction of the abdominal aorta above the bifurcation was confirmed. Subsequent embolectomy was performed and an embolus consisting of several layers of different age was extracted. After successful surgical intervention with subsequent clinical improvement, the patient's clinical condition deteriorated a few day later. She died on day 9 after surgery from a complete ischemia of the small intestine and the colon ascendens.

Aged↗
PubMed1998

Measurement of left ventricular maximal isovolumetric pressure in rats: effects of antihypertensive drugs and diabetes mellitus.

We developed a method for measuring left ventricular maximal isovolumetric pressure (LVMIP) in intact rats and applied it in the presence of acutely administered antihypertensive drugs and in experimental diabetes mellitus. The combination of a 2 French Fogarty arterial embolectomy balloon catheter with a new ultra-thin shaft (0.25 mm diameter) Millar ultra-miniature pressure tip catheter was used. Closed-chest, thiopental anaesthetized female Sprague-Dawley rats received the beta-adrenoceptor blocker metoprolol (1 mg/kg/h), the alpha-adrenoceptor blocker prazosin (0.1 mg/kg/h), and the calcium antagonist nifedipine (0.5 mg/kg/h). They were applied as continuous i.v. infusion for 30 minutes. The angiotensin II type 1 (AT1) receptor antagonist losartan (3 mg/kg) was applied as bolus i.v. injection. Diabetes mellitus was induced by a single tail vein injection of streptozotocin (60 mg/kg) five weeks prior to hemodynamic measurements. Under control conditions, left ventricular systolic pressure (LVSP) was 136.5 +/- 3.7 mmHg and increased to 263 +/- 5.4 mmHg when the balloon was inflated (LVMIP). LVSP was significantly lower in the presence of prazosin, metoprolol, nifedipine, and in diabetic rats. However, LVMIP was significantly reduced only in the metoprolol-treated and diabetic rats. Both LVSP and LVMIP did not change significantly in losartan-treated rats. The degree of the increase in left ventricular maximal isovolumetric pressure during balloon inflation (LVMIP-LVSP) was not significantly different in any experimental condition. These results suggest that the mechanism for evoking LVMIP is not dependent on the acute stimulation of cardiac alpha- and beta-adrenergic receptors, on calcium channels, nor on the AT1 receptors. In addition, the intrinsic mechanism for the generation of LVMIP seems not to be influenced in the diabetic state.

Adrenergic alpha-Antagonists↗
PubMed1998

Vascular remodeling in balloon injured rabbit iliac arteries.

To characterize long-term vascular remodeling associated with neointimal formation in vivo, we established a model of balloon injury in normal chow fed rabbits. The iliac artery was injured by denudation using a 2F embolectomy catheter. Injured vessels were removed after perfusion fixation (90 mm Hg) in situ at 2, 4, 6, and 12 weeks post-injury; control vessels were obtained from 2- and 12-week age-matched, uninjured animals. Intimal growth was observed in all animals post-injury. Intimal area averaged 0.13 +/- 0.02 mm2 2 weeks post-injury and continued to increase at 4 and 6 weeks post-injury; +38% and +77% relative to the 2-week time point, respectively. Medical areas were similar among the 2-, 4-, and 6-week injury groups and the 2- and 12-week control groups. From 6 to 12 weeks post-injury, both intimal and medial areas decreased significantly (30% and 34%, respectively); while lumen area increased 53% from 4 to 12 weeks and overall vessel size (area enclosed by the external elastic lamina) remained the same. These data demonstrate that intimal and medial thinning contribute to long term maintenance of lumen area in response to neointimal formation.

Animals↗
PubMed1998

Vascular remodeling in balloon injured rabbit iliac arteries.

To characterize long-term vascular remodeling associated with neointimal formation in vivo, we established a model of balloon injury in normal chow fed rabbits. The iliac artery was injured by denudation using a 2F embolectomy catheter. Injured vessels were removed after perfusion fixation (90 mm Hg) in situ at 2, 4, 6, and 12 weeks post-injury; control vessels were obtained from 2- and 12-week age-matched, uninjured animals. Intimal growth was observed in all animals post-injury. Intimal area averaged 0.13 +/- 0.02 mm2 2 weeks post-injury and continued to increase at 4 and 6 weeks post-injury; +38% and +77% relative to the 2-week time point, respectively. Medical areas were similar among the 2-, 4-, and 6-week injury groups and the 2- and 12-week control groups. From 6 to 12 weeks post-injury, both intimal and medial areas decreased significantly (30% and 34%, respectively); while lumen area increased 53% from 4 to 12 weeks and overall vessel size (area enclosed by the external elastic lamina) remained the same. These data demonstrate that intimal and medial thinning contribute to long term maintenance of lumen area in response to neointimal formation.

Animals↗
PubMed2003

Superior mesenteric arterial embolism: treatment by trans-catheter thrombo-aspiration.

A 57-year-old woman with hypertension, mixed mitral valve disease, and atrial fibrillation was admitted to our hospital because of abdominal pain continuing for several hours. On the following day, colonoscopy was performed, and diffuse yellow-white pseudomembranous changes were seen in the right hemicolon, but there were no abnormal findings in the left hemicolon; 24 h after onset, a diagnosis of superior mesenteric arterial embolism was made on the computed tomography (CT) scan findings. Abdominal angiography was performed and showed complete occlusion of the superior mesenteric artery (SMA). Then conservative treatment, using per-catheteric thrombus aspiration, was done, followed by intraarterial injection of tissue type plasminogen activator. After the thrombo-aspiration, the filling deficit of the main artery had disappeared, and the branches on the right side were clearly delineated. After the treatment, the symptoms such as abdominal pain and diarrhea improved accordingly. She was discharged from the hospital 27 days later. Our case suggests that trans-catheter thrombo-aspiration is a possible alternative to open embolectomy for some cases of SMA embolism more than 10 h post-onset.

Catheterization↗
PubMed2004

One-lung ventilation for video-assisted thoracoscopic interruption of patent ductus arteriosus.

PURPOSE: Video-assisted endoscopic techniques have recently been employed in congenital heart surgery for patent ductus arteriosus (PDA) interruption. We report our preliminary experience of using a new technique of single-lung ventilation to perform video-assisted thoracoscopic PDA interruption (VATS-PDA) in small infants and children. METHODS: Sixteen infants with a mean body weight of 6.5 +/- 2.4 kg (range 2.6-12.8 kg) underwent VATS-PDA under selective right-lung ventilation using a 2-F balloon catheter for arterial embolectomy. RESULTS: We did not need to reposition the retractor or reinflate the atelectatic lung, as there was no transient hypoxia or hypercarbia. The mean procedure time was 81 +/- 27 min (range 45-145 min) and all patients, with the exception of one with a total anomalous pulmonary venous connection, were extubated in the operating room. CONCLUSION: This technique using single-lung ventilation for infants and small children was safe and effective in providing pediatric thoracic access and exposure within confined and delicate anatomic spaces.

Cardiac Catheterization↗
PubMed2002

Spontaneous superficial femoral artery dissection with distal embolization.

Primary arterial dissection of the peripheral vessels is a rare condition. We report a case of spontaneous dissection of the distal superficial femoral artery compounded by distal embolization leading to ischemic symptoms. The patient was successfully treated with exploration of the superficial femoral artery over the area of the dissection, distal embolectomy, and reconstruction by way of an interposition graft. Awareness of this condition leads to potentially earlier diagnosis and expands the therapeutic options.

Aortic Dissection↗
PubMed2002

Lower extremity revascularization without preoperative contrast arteriography: experience with duplex ultrasound arterial mapping in 485 cases.

This study reviews our experience with duplex ultrasound arterial mapping (DUAM) for preoperative evaluation in 466 patients (262 men) who underwent 485 lower extremity revascularization procedures from January 1, 1998 to May 30, 2001. Preoperative imaging consisted of DUAM alone in 449 procedures and DUAM and contrast angiography (CA) in 36. An attempt to image from the distal aorta to the pedal arteries was made in all the patients. The selection of optimal inflow and outflow bypasses anastomotic sites was based on a schematic drawing following DUAM examination. Inflow disease was also assessed by intraoperative pressure gradient (IPG) between the distal anastomosis and radial arteries, and completion arteriography of the runoff vessels was obtained, which was correlated with the preoperative findings. Indications for surgery were severe claudication in 91 (19%) limbs, tissue loss in 197 (40%), rest pain in 113 (23%), acute ischemia in 46 (10%), popliteal aneurysm in 18 (4%), superficial femoral artery aneurysm in 1, abdominal aortic aneurysm with claudication in 1, and failing graft in 18 (4%). Age ranged from 30 to 97 years (mean 72 +/- 12 (SD) years) and risk factors such as diabetes, hypertension, use of tobacco, coronary artery disease, and end-stage renal disease were present in 45%, 45%, 44%, 44%, and 13% of the patients, respectively. One hundred twenty-one (25%) limbs had at least 1 previous ipsilateral revascularization. The mean DUAM time was 66 +/- 20 (SD) min (30-150 min). Additional preoperative imaging was deemed necessary in 36 cases due to extensive ulcers, edema, severe arterial wall calcification, and very poor runoff. The distal anastomosis was to the popliteal artery in 173 cases and to the tibial and pedal arteries in 255. Inflow procedures to the femoral arteries, embolectomy, thrombectomy, balloon angioplasty, and patch angioplasty accounted for the remaining 57 cases. Overall, 6-, 12-, and -24- month secondary patency rates were 86%, 80%, and 66%, respectively. This early experience shows that high-quality arterial ultrasonography performed by a highly skilled vascular technologist may represent an alternative to conventional arteriography for patients in need of lower extremity revascularization. Because of limitations inherent to the technique and very poor runoff observed on ultrasonographic examination, additional preoperative imaging procedure's are needed for certain patients.

Adult↗