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PubMedDate not supplied

Use of a temporary caval filter to assist percutaneous iliocaval thrombectomy: experimental results.

PURPOSE: To test a new filter design that allows coaxial insertion of thrombectomy devices and active clot removal. MATERIALS AND METHODS: A prototype filter system was used in animal experiments. It is a transjugularly inserted coaxial system with a 16-F outer sheath and an inner tube that is covered by a tulip-shaped meshwork with a 22-mm diameter at its inserted end. The inner tube allows insertion of instruments up to 8 F. The filter was developed to assist with percutaneous mechanical thrombectomy in the iliofemoral and caval veins. The filter has been used as an assisting tool in nine sheep and eight pigs. It was combined with an impeller system in nine sheep for caval thrombectomy and with a hydrodynamic catheter for iliac thrombectomy in eight pigs after artificial induction of iliac or caval thrombosis. RESULTS: The filters captured emboli from the intervention in six of nine sheep. The amount of captured emboli was reduced within the filter cone by the impeller instrument in five of six instances. Residual thrombus was removed by closing the filter in five of six sheep. In pigs, the filter captured emboli in three cases during hydrodynamic embolectomy. Pulmonary embolization did not occur with the filter in place. After filter removal, minor pulmonary clot embolization occurred in one case. CONCLUSION: The temporary tulip filter was effective in these animal models in capturing and removing thrombus material that may dislodge from iliocaval veins during mechanical thrombectomy.

Animals↗
PubMedDate not supplied

Biochemical analysis of collagen and elastin synthesis in the balloon injured rat carotid artery.

INTRODUCTION: Balloon catheter denudation of the endothelium in the common carotid artery of the rat is routinely used as a model of neointimal lesion development. The response to endothelial denuding injury involves proliferation and migration of medial smooth muscle cells (SMCs), with the formation of a dramatically thickened neointima. While many studies have focused on the kinetics of the early proliferative and migration responses, much less attention has been paid to the pronounced accumulation of extracellular matrix that occurs as the neointima grows. The purpose of this study was to measure collagen and elastin content, and to assess collagen and elastin synthesis in injured rat carotid arteries. METHODS: Male Sprague-Dawley rats were subject to balloon catheter injury of the left carotid artery using a 2F embolectomy catheter. Rats were sacrificed at different time points after injury, and both carotids left (injured) and right (uninjured and control) were used for measurement of elastin and collagen synthesis (7 days) and content (7, 21 and 60 days). RESULTS: Elastin and collagen syntheses were significantly increased in the injured carotids at 7 days after injury. The increase in elastin synthesis was more dramatic (100% compared to control) than the increase in collagen synthesis (50% compared to control). Both elastin and collagen content were significantly increased by 21 days, and contents were further increased by 60 days in the injured carotid compared to uninjured controls. At 60 days, collagen content of the injured vessels was 2.09+/-0.01 mg/arterial segment compared to 1.32+/-0.08 mg/arterial segment in controls (P=.01). Elastin content of injured vessels was 2.40+/-0.43 mg/arterial segment compared to 1.19+/-0.25 mg/arterial segment in controls (P=.03). CONCLUSIONS: Collagen and elastin contents were significantly increased following injury of the rat carotid. This study provides for the first time a biochemical assessment of collagen and elastin in the balloon-injured rat carotid artery.

Animals↗
PubMed1998

Operative mortality and long-term survival of patients operated on for acute lower limb ischaemia.

OBJECTIVES: To investigate the operative mortality and long-term survival of patients with lower limb embolism or acute thrombosis. DESIGN: A retrospective survival analysis. MATERIALS: Eighty patients with acute thrombosis treated by bypass and 192 patients with embolism treated by embolectomy during the years from 1985 to 1996 were studied. METHODS: The observed survival rates were calculated with the product limit method. The expected survival rates were estimated from death-rate tables. The standard mortality rate was compared over a 5-year follow-up. RESULTS: The patients treated for embolism had an operative mortality of 17% and a 5-year survival rate of 17%, which was significantly lower than the expected rate of 62%. Those treated for acute thrombosis had an operative mortality of 14% and a 5-year survival rate of 44%. This was significantly higher than for the embolism group, but significantly lower than the expected rate of 74%. Both groups had a standard mortality rate of 2.2 at 5 years. CONCLUSION: Patients with acute ischaemia have a poor short-term and long-term prognosis. The patients treated for embolism are older and they have a shorter life expectancy than those treated for acute thrombosis. The standard mortality rate of the two groups appears similar.

Aged↗
PubMed1998

Early experience with stenting for iliac occlusive disease.

OBJECTIVES: To review our experience of iliac artery stenting for occlusive disease. DESIGN: Prospective study of 50 consecutive patients with iliac occlusive disease, November 1993-November 1996. The indications for stenting were complete iliac occlusion (37) restenosis (four), donor site inflow for bypass grafting (four) and difficult stenoses (> 90% and/or > 5 cm) (five). The majority of patients (41) presented with intermittent claudication. RESULTS: All 13 stenoses were successfully stented. One occluded but the rest remain patent. There were no other complications. By contrast, it was not possible to place a stent across 10 of the 37 complete iliac occlusions. In this group there were nine major complications, including five patients who required early embolectomy (four femoral, one brachial) and one patient who developed a false aneurysm at the site of the stent. The "intention to treat" primary cumulative patency for iliac occlusions was 65% at 2 years but after excluding technical failures was 88%. CONCLUSIONS: There is a sharp learning curve and significant complication rate associated with stenting complete occlusions. However, following successful stenting patency rates are around 90% for both iliac stenoses and occlusions.

Aged↗
PubMed2000

Management of deep venous thrombosis and pulmonary embolism.

The management of deep venous thrombosis (DVT) and pulmonary embolism (PE) is changing dramatically. The US Food and Drug Administration has approved outpatient treatment of DVT with the low-molecular-weight heparin enoxaparin as a bridge to warfarin. Warfarin use is improved by avoiding loading doses and by recognizing previously unappreciated interactions and potentiation with commonly used medications such as acetaminophen. The importance of isolated calf and upper-extremity venous thromboses has been validated, so that patients with these conditions routinely undergo anticoagulation. Risk stratification for PE is becoming more sophisticated because practitioners now assess right ventricular function (usually by echocardiography) instead of relying solely on systemic arterial blood pressure and heart rate to determine prognosis. Among patients with massive DVT or hemodynamically unstable PE, thrombolysis, thrombectomy, and embolectomy (often performed in an interventional angiography laboratory) are being used with increasing skill and improved outcomes.

Humans↗
PubMedDate not supplied

Topical application of beta-radiation to reduce intimal hyperplasia after carotid artery balloon injury in rabbit. A possible application for brachytherapy in vascular surgery.

PURPOSE: Endovascular brachytherapy for the prevention of intimal hyperplasia (IH) and restenosis after balloon/stent angioplasty has proven effective both in animal preparations and clinical trials. A variety of beta-emitting isotopes and catheter-based devices have been developed for the delivery of low-dose radiation in clinical coronary and peripheral trials. No platform, however, has yet been developed for brachytherapy in concert with vascular surgical operations. The purpose of this study was to evaluate the vascular histopathologic response following balloon injury to rabbit carotid arteries with and without topically applied low-dose beta-radiation. METHODS: The beta-emitting isotope strontium-90 (Sr-90) was conjugated onto the matrix of polypropylene (PLYP) mesh. Rabbit carotid arteries were balloon-injured with a #2 embolectomy catheter. Six carotid arteries were wrapped with nonradioactive PLYP mesh (controls) and Sr-90 ( approximately 90 microCi) PLYP mesh in order to deliver low-dose radiation to the vessel wall from the external (adventitial) surface. Tissue was harvested at 6 weeks and processed for histologic examination. RESULTS: There was consistent blockade of fibrocellular neointima formation with virtually no neointima present in all treated segments, compared to moderate neointima formation in controls. Medial thinning and smooth muscle cell (SMC) necrosis were also associated with topical brachytherapy. CONCLUSION: beta-Radiation applied by an externally wrapped PLYP mesh labeled with Sr-90 markedly suppressed neointima formation in an animal vascular surgical injury model. Further studies, however, are necessary to determine a suitable isotope and dosage for clinical application.

Administration, Topical↗
PubMed2002

Isoprostanes--markers of ischaemia reperfusion injury.

Ischaemia reperfusion injury is a common and important phenomenon that occurs predictably in patients undergoing such procedures as cardiopulmonary bypass, thrombolysis, surgery under tourniquet, organ transplantation or embolectomy. Oxidative stress and the resulting lipid peroxidation play a major role in reperfusion injury. Membrane and cellular dysfunction result and, subsequently, organ injury or failure may ensue. Traditional methods of quantifying ischaemia reperfusion injury, including measurement of malondialdehyde, lack specificity and sensitivity. It was reported in 1990 that isoprostanes, a series of prostaglandin-like compounds, are produced by the free radical-catalyzed peroxidation of arachidonic acid. Measurement of the isoprostane concentration in urine or plasma provides the most reliable, non-invasive method currently available to assess oxidative stress in vivo. Serial measurement of isoprostanes in biological fluids has enhanced our understanding of the mechanisms underlying ischaemia reperfusion injury itself and its role in certain diseases. Furthermore, measurement of the isoprostane concentration provides a means to assess the effects of prophylactic and therapeutic interventions. In the future, the development of rapid, simple assays for isoprostanes offers the potential to assess prognosis during and after ischaemia reperfusion events.

Biomarkers↗
PubMed2002

Idiopathic free-floating thrombus of the common carotid artery.

BACKGROUND: The observation of an intraluminal common carotid artery thrombus overlying a wall defect at ultrasonography or angiography is unusual. To our knowledge, there are no previous reports of a free-floating thrombus in the common carotid artery. CASE REPORT: A 45-year-old woman who was previously healthy and on no medications presented with acute hemiparesis and aphasia. Following testing that included carotid duplex and transcranial Doppler ultrasonography, diffusion-weighted magnetic resonance imaging, and digital subtraction angiography, the patient underwent emergency open embolectomy. No underlying wall defect was seen at the time of imaging or surgery. No obvious hypercoagulable state could be identified. Her NIH Stroke Scale score improved from 26 at admission to 2 at three months and 1 at one year. CONCLUSIONS: Multimodal imaging may have improved diagnosis and management in this patient with a unique finding. The source of the thrombus remains obscure.

Carotid Artery Diseases↗
PubMed2001

Sarcoma of the mitral valve causing coronary arterial occlusion in children.

Primary tumors of the cardiac valves are rare. One of the most common reasons that left-sided cardiac tumors come to clinical attention is embolization to the systemic circulation. We present two children who suffered left coronary arterial occlusion due to embolization of a sarcoma of the mitral valve. A 6-year-old female who had been admitted to the hospital after cerebrovascular embolization of a fragment of sarcoma of the mitral valve experienced sudden cardiovascular collapse due to occlusion of the left coronary artery. She was placed on extracorporeal membrane oxygenation, and underwent coronary embolectomy and resection of the tumor from the mitral valve and its tendinous cords. Left ventricular function did not improve, and she underwent orthotopic heart transplantation. On follow-up 32 months after transplant, the patient is well, with no evidence of recurrence of or metastasis from the tumor. The tumor arose from the leaflets and tendinous cords of the mitral valve, and was composed grossly of multiple white nodules. Histopathologic evaluation disclosed fragments composed predominantly of peripheral spindle cells in an extensive fibromyxoid stroma. The mildly pleomorphic cells of the tumor gradually blended with adjacent pieces of the mitral valvar leaflet and tendinous cords. Immunohistochemical studies revealed strong staining for vimentin, smooth muscle actin, muscle specific actin, and myoglobin, suggesting myogenic differentiation. The other patient was a 2 1/2-year-old female who died suddenly at home. Grossly and histologically, the tumor was essentially identical to the first case, and there was a 3 cm string-like extension passing into the orifice of the left coronary artery. To put the cases in context, we compare them with other descriptions of this rare type of tumor.

Child↗
PubMed1999

[Vena cava filter for prevention of pulmonary embolism].

Vena caval filters in the prevention of pulmonary embolism All currently available caval filters can be implanted percutaneously in local anaesthesia. In the USA the FDA has approved the stainless steel Greenfield filter, the Titanium Greenfield filter, the Bird's Nest filter, the LGM or VenaTech filter and the Simon Nitinol filter. Some other caval filters are commercially available in Europe, but there exist only few clinical trials about them. The Greenfield filter is implanted since the early seventies and the greatest amount of data has been published about it. Standard indications for filter placement are recurrent pulmonary embolism despite adequate anticoagulation, in patients after pulmonary embolectomy, when there is a contraindication to anticoagulation (e.g. fresh surgical wound, active gastrointestinal bleeding, recent haemorrhagic stroke, major trauma,...) and when serious complications occur after thrombolysis or anticoagulation. In patients who suffer from severe cardiopulmonary disease both a caval filter and anticoagulation may be required. Follow-up investigations include plain abdominal radiography and duplex ultrasound, in special cases computed tomography, cavography, magnetic resonance imaging in newer filter types, and intravascular ultrasound. Complications include recurrent pulmonary embolism, caval obstruction, migration, fracture and perforation of filter struts. As clinically relevant complications are rare, in diligently selected cases the patient will benefit from implantation of a caval filter.

Device Approval↗
PubMed2003

Treatment of acute embolic occlusions of the subclavian and axillary arteries using a rotational thrombectomy device.

Acute embolic or local thrombotic ischaemia of the upper limbs can be treated by embolectomy or by endovascular techniques. We report here on the endovascular thrombectomy of acute embolic occlusions of subclavian and axillary arteries in two patients using a rotational thrombectomy device and give an overview about the actual literature. Two female patients, each with a history of multivessel coronary disease and intermittent atrial fibrillation, complained of sudden onset of pain at rest and paleness of the left and right arm, respectively. Duplex ultrasound showed a localized embolic occlusion of the left subclavian artery and the bifurcation of the brachial artery in the first patient and a localized embolic occlusion of the distal right subclavian and axillary artery in the second patient. In the first patient, the left subclavian artery was reopened using a 8F-Rotarex device via the femoral access, while the bifurcation of the brachial artery was reopened by local thrombolysis using 25 mg rt-PA because of the insufficient length of the thrombectomy device of 80 cm. In the second patient, the right subclavian and axillary arteries were reopened using a 6F-Rotarex device. Follow-up examinations before discharge and after 6 months showed normalized perfusion of the arms of both patients.

Acute Disease↗
PubMed2002

Renal allograft loss due to proximal extension of ileofemoral deep venous thrombosis.

Renal allograft recipients with thrombophilic (hypercoagulable) states are at higher risk for early allograft loss. Presumably, the combination of endothelial injury at surgery and thrombophilia predisposes to arterial or venous thrombosis. Of 270 consecutive renal transplants at our center one allograft failed secondary to renovascular thrombosis. At exploration the iliac and renal veins were thrombosed. Thrombectomy and re-implantation were attempted, but unsuccessful. Also noted at surgery was extensive clot in the femoral vein that could not be removed by embolectomy catheters. Post-operatively, a Doppler ultrasound confirmed the presence of extensive deep venous thrombosis (DVT) in the femoral and popliteal veins. The adherent nature of this clot, the extent of clot found less than 12 h after renal transplantation and the absence of leg edema suggested that the DVT existed prior to surgery. This case demonstrates that a pre-existing, asymptomatic DVT can precipitate allograft thrombosis and highlights the importance of diagnosing thrombophilia in patients undergoing renal transplantation. Current practices in our unit have evolved to include screening for thrombophilia in all patients with a suggestive history. As thrombophilic states are increasingly appreciated in the end-stage renal disease population, effective management of these patients while on hemodialysis and at the time of renal transplantation presents an ongoing challenge.

Adult↗
PubMed1994

Recovery from paraplegia following aortic saddle embolism. Case report.

An aortic saddle embolus causing paraplegia is rare and even rarer is a documentation of neurological recovery from this event. A 47 year old male presented with absent pulsations in the lower limbs and paraplegia, both of sudden onset. He underwent immediate bilateral transfemoral embolectomy. The postoperative period was stormy. The paraplegia recovered over a period of 2 months and he could walk to his place of work after 6 months. The rare combination of saddle embolus and paraplegia is discussed. An attempt has been made to verify the hypothesis of Dickson et al which states that a low origin of the great radicular artery (GRA) below T12 level may be responsible for paraplegia when obstructed by a saddle embolus. We found the GRA arising at L2 vertebral level in this patient. Postoperative selective spinal arteriogram and magnetic resonance imaging (MRI) of the spinal cord showed a patent GRA and normal spinal cord structure respectively. Early surgical intervention in restoring the blood flow into the GRA may prevent severe histological changes hitherto responsible for nonrecovery from paraplegia in the earlier reports.

Aortic Diseases↗
PubMedDate not supplied

The early history of cardiac surgery in Stockholm.

Cardiac surgery in Stockholm grew on a sound foundation of well-developed general thoracic surgery. The portal figure is Clarence Crafoord (1899-1983) who already in 1927 had succeeded with the Trendelenburg pulmonary embolectomy operation. He went on to develop lung surgery in general. With foresight he stimulated the chemists of Karolinska Institute to purify heparin, first for prophylaxis against venous thromboembolism and later for use with the heart-lung machine. In 1944 he became the first surgeon to successfully operate on patients with coarctation of the aorta. With Viking Olov Bjork and Ake Senning the heart-lung machine was improved, finally allowing its clinical use in a patient operated in 1954 for a myxoma of the left atrium, with long-term survival. This was the first successful use of the heart-lung machine in Sweden and the second in the world. He and his coworkers, first at the Sabbatsberg hospital and from 1957 at the Karolinska hospital made major contributions to cardiology and radiology, apart from the progresses in cardiac surgery. Contributions such as pressure recording from the left atrium by needle puncture in 1950, the Senning operation for transposition of the great arteries and the first use of a totally implantable cardiac pacemaker in 1958 are indeed medical history.

Aortic Coarctation↗
PubMed1999

Vascular surgical society of great britain and ireland: provision of an emergency vascular service: a three-hospital model

BACKGROUND: A new emergency vascular cover service came into effect on 1 May 1997 involving three district general hospitals, eight surgeons and covering a patient population of 600 000. Each week one of the three hospitals is on call, accepting the transfer of patients requiring urgent surgical or radiological vascular intervention between 17.00 and 09.00 hours each weekday and throughout the weekend from the other two hospitals. The aim of this project was to evaluate the pattern, appropriateness of referral and increased workload in the first year following the implementation of this model of emergency vascular cover. METHODS: A retrospective study of case notes was conducted identifying all acute vascular emergency admissions from each hospital. RESULTS: The total number of emergency admissions when on call was 140; 71 per cent were admitted via bed bureau/accident and emergency, 26 per cent were transfers from the other two hospitals and 3 per cent were transfers from elsewhere. Some 66 per cent of admissions occurred between 17. 00 and 09.00 hours or at weekends; 36 per cent required emergency operation. Of these patients, 42 per cent required abdominal aortic aneurysm repair, 42 per cent an embolectomy, 11 per cent an amputation and 5 per cent another procedure. Consultants performed 58 per cent of the emergency operations, specialist registrars 37 per cent and senior house officers 5 per cent. Of the total number of emergencies admitted, 12 per cent required intensive care unit facilities. Some 63 per cent of the patients were finally discharged, 11 per cent were transferred and 25 per cent died. CONCLUSION: These data demonstrate that one consultant-led vascular team can provide an out-of-hours emergency vascular service for a population served by three hospitals. The workload is manageable without the predicted drain on resources and is preferred by the participating consultants.

Journal Article↗
PubMed1997

Paediatric one lung ventilation in the prone position.

Pulmonary lobectomy in the presence of infected secretions requires isolation of the affected lung to prevent soiling of the healthy lung. In young children this is usually accomplished using a Fogarty embolectomy catheter. We report the successful combination of a Fogarty catheter, a tracheal tube and the prone position, which provided adequate ventilation and oxygenation as well as excellent surgical exposure.

Bronchiectasis↗
PubMed2000

Early experience of intra-ureteric capsaicin infusion in loin pain haematuria syndrome.

OBJECTIVES: To evaluate early results of the intra-ureteric instillation of capsaicin for the treatment of loin pain haematuria syndrome (LPHS). PATIENTS AND METHODS: Ten patients with LPHS were treated using intra-ureteric capsaicin instillation. A solution of capsaicin was infused into the affected ureter through an embolectomy catheter, under anaesthesia. The success of the treatment was assessed using patient questionnaires and the quantitative reduction in the patients' analgesic requirements measured. RESULTS: During a mean follow-up of 6 months, six of the 10 patients had short- to medium-term symptomatic relief after one or more treatments; four had no relief from their symptoms. One patient had a mucosal ulceration in the bladder after extravasation of the capsaicin solution. Two patients subsequently underwent simple nephrectomy for symptomatic nonfunctioning kidneys. CONCLUSION: These results are consistent with other preliminary reports of the efficacy of capsaicin treatment in LPHS and such treatment therefore has a definite therapeutic role in this difficult condition. We are uncertain if the treatment contributed to the deterioration of the excised kidneys. This early experience suggests a need for careful consideration when contemplating this treatment, with attention directed to both the initial diagnosis and possibly the technique of capsaicin/instillation. We include a protocol to follow when preparing patients for capsaicin treatment.

Administration, Topical↗