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PubMed1998

Subclavian vascular access stenosis in dialysis patients: natural history and risk factors.

Stenosis of the subclavian vein (SVS) after cannulation occurs in 15 to 50% of chronic hemodialysis patients, and impedes the placement of an arteriovenous fistula in the ipsilateral arm. Its natural history and pathogenic mechanisms are not well established. This study examined 42 consecutive chronic renal failure patients (28 men and 14 women; 46+/-19 yr) in whom subclavian catheters had been placed as the initial vascular access for hemodialysis. All patients underwent sequential venography studies: at baseline (24 to 48 h after removal of the catheter) and 1, 3, and 6 mo thereafter. Venograms were considered abnormal when there was evidence of unequivocal strictures (more than 30% narrowing), with or without collateral circulation. At baseline, 52.4% (n=22) of patients showed stenotic vein lesions (n=19) or total thrombosis (n=3), and identical lesions were also observed after 1 mo. Surprisingly, 10 of 22 patients with initial SVS (45.4%) showed spontaneous recanalization of venous lesions in the venographies performed 3 mo after removal. The patients with normal baseline venograms (n=20) showed no change during follow-up. Patients with definitive stenosis at 6 mo (n=12) had a higher number of inserted catheters (1.58+/-0.6 versus 1.2+/-0.48; P < 0.05), longer time in place (49.08+/-32.2 versus 29.03+/-26.6 d; P < 0.05), and higher number of dialysis sessions (21+/-13.8 versus 12.4+/-11.4; P < 0.05) than those without SVS or with spontaneous recanalization of venous lesions during follow-up. Furthermore, a higher number of catheter-related infections were observed in patients with definitive SVS (66.6% versus 33.3%; P < 0.05). In summary, SVS is observed in more than half of patients 24 to 48 h after catheter removal and 1 mo later. Even when recanalization occurs in many cases, a definitive stenosis is seen in 28% of patients by the third month. Thus, the creation of an ipsilateral vascular access is possible provided that venography is normal at this time. Finally, mechanical factors and catheter-related infections are the major risk factors for the development of late SVS.

Adult↗
PubMed1994

Long-term efficacy of acute thrombolytic therapy for myocardial infarction.

We conducted a retrospective study (1981-1990) to determine whether the efficacy of intracoronary thrombolysis (ICT) could be evaluated from data obtained solely after recanalization. We investigated 55 successful ICT patients (38 with anterior and 17 with inferior myocardial infarction (MI)), and 31 control infarct patients without recanalization. The total serum creatine phosphokinase release (sigma CPK), the extent of infarction measured by T1-201 single photon emission computed tomography (total DS) and the disturbance of regional wall motion (asyn.%) were investigated as parameters for distinguishing the successful ICT and control groups. Discriminatory ability for the two groups was highest with the total DS in all patients. Only the total DS differed significantly between the two groups in patients with inferior infarction. Misidentification of control patients as successful patients was least frequent (25.5%) when using the total DS. These findings suggest that the effectiveness of ICT for acute MI may be assessed on the basis of data obtained solely after recanalization, with the total DS being particularly useful.

Adult↗
PubMed1995

Changes in coagulation and fibrinolytic system after local intra-arterial thrombolysis for acute ischemic stroke.

Intracerebral hemorrhagic transformation is one of the most important complications of thrombolytic therapy for acute ischemic stroke. The relationship between changes in markers for the coagulation and fibrinolytic systems and occurrence of hemorrhagic transformation was determined after local intra-arterial thrombolytic therapy using urokinase (UK) (24 patients) or recombinant tissue plasminogen activator (t-PA) (10 patients) within 6 hours of onset. All 34 patients had no hypodensity areas on initial computed tomography scans. Plasma concentrations of fibrinogen-fibrin degradation products (FDP), fibrinogen, alpha 2-plasmin inhibitor (alpha 2-PI), plasmin-alpha 2 plasmin inhibitor complex (PIC), thrombin-antithrombin III complex (TAT), and D-dimer were measured. Hemorrhagic transformation occurred in seven patients (21%) with complete or partial recanalization; four in the UK group and three in the t-PA group. Doses of the thrombolytic agents did not correlate with the incidence of hemorrhagic transformation. The FDP levels in the hemorrhagic transformation group treated with UK significantly increased immediately and 1 hour after the therapy. The alpha 2-PI activities decreased and PIC levels increased in both the hemorrhagic transformation and the nonhemorrhagic groups after the therapy. The TAT levels in both groups tended to be higher than the normal range, but there was no significant difference from the pretreatment levels. The D-dimer levels in the hemorrhagic transformation group were higher than those in the nonhemorrhagic group at 24 hours after the therapy. Furthermore, the D-dimer levels were significantly higher in patients with complete recanalization compared with those with none or partial recanalization.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1998

Embolization of cerebral aneurysms using Guglielmi detachable coils--problems and treatment plans in the acute stage after subarachnoid hemorrhage and long-term efficiency.

This study investigated the problems in treating ruptured aneurysms using Guglielmi detachable coils (GDCs) in the acute stage and evaluated the long-term efficacy in a series of 25 patients with 29 aneurysms. Eight patients with ruptured aneurysm treated within 2 weeks of the onset of subarachnoid hemorrhage (SAH) suffered no mortality or morbidity related to the procedure. Five patients achieved good outcomes despite severe SAH and returned to their previous lives. Three patients had poor clinical outcomes, two related to vasospasm and one related to pulmonary complication. More than 9 months follow-up was completed in 14 patients with 16 aneurysms. All six small aneurysms with small necks were completely obliterated and no recanalization was seen, and two of the eight large or giant aneurysms were completely obliterated. Recanalization was seen in four large or giant aneurysms and one small aneurysm due to coil compaction within 13 months. One patient died of rupture of a large aneurysm 18 months after complete obliteration of the aneurysm. Embolization using GDCs in the acute stage after SAH can prevent rerupture of cerebral aneurysms. However, recanalization due to coil compaction was the major problem in the chronic stage. Intensive follow-up and additional embolization, if necessary, is important.

Aged↗
PubMed2006

Predictors of angiographic changes in neck remnants of ruptured cerebral aneurysms treated with Guglielmi detachable coils.

The angiographic changes in neck remnants of ruptured cerebral aneurysms treated with Guglielmi detachable coils (GDCs) were evaluated in the acute stage to analyze the important radiological and clinical factors. The clinical and radiological data of 37 patients with a residual neck of a ruptured cerebral aneurysm treated with GDC were reviewed. The angiographic changes on follow-up angiography were classified into three groups: recanalization of the neck remnant, progressive thrombosis, and unchanged. The effects of the clinical and angiographic findings, such as patient age, follow-up period, type of aneurysm (terminal type or side wall type), dome diameter, neck size, dome/neck ratio, obliteration rate, and volume embolization ratio were investigated. Recanalization of the neck remnant was observed in 18 of 37 cases, progressive thrombosis in nine, and unchanged in 10. The type of aneurysm, dome diameter, neck size, and volume embolization ratio were correlated with changes in the neck remnant. The aneurysm dome diameter and type of aneurysm were independent predictive factors for the recanalization of neck remnants on follow-up angiography. Dome diameter of less than 4.5 mm and volume embolization ratio of more than 31% in side wall aneurysms were likely to lead to progressive thrombosis.

Adult↗
PubMed1988

Laser thermal angioplasty for the treatment of obstruction of the distal superficial femoral or popliteal arteries.

The success rates and clinical effectiveness of percutaneous laser thermal angioplasty for obstruction of the distal superficial femoral or popliteal arteries were assessed. Laser thermal angioplasty was performed with the first commercially available laser system on 25 atherosclerotic vascular lesions in 20 lower extremities of 18 patients. Fifteen of the lesions were occlusions (average length, 5.6 +/- 3.1 cm), and 10 were high-grade stenoses (average length, 2.6 +/- 1.8 cm). Indication for angioplasty was claudication limiting life-style in 12 extremities and threatened limb loss in eight. All patients were treated with a 1.5- or 2.0-mm metal-capped optical fiber attached to a 14-W argon-ion laser. Balloon angioplasty was performed after laser recanalization in all successful cases. The patients were followed by Doppler ankle/brachial index and clinical evaluation. Laser thermal angioplasty was technically successful (vessel recanalization) in 18 (90%) of 20 of the cases. Fourteen (70%) of 20 extremities were successes by ankle/brachial index follow-up, while 15 (75%) of 20 remained clinically improved after an average follow-up of 7.8 +/- 5.3 months. Laser thermal angioplasty has a technical and clinical success rate that compares favorably with previous reports of balloon angioplasty. With proper patient selection, laser thermal angioplasty can reduce the difficulty of traversing lesions that are amenable to standard balloon angioplasty and increase the number of vascular lesions that can be treated percutaneously but could not be recanalized without the use of laser energy.

Aged↗
PubMed1987

Indications for endoscopic neodymium-YAG laser treatment in the gastrointestinal tract. Twelve years' experience.

Application of clinical endoscopic Nd:YAG laser (lambda = 1.06 micron) therapy has been introduced in 1975. It is suitable to stop all kinds of gastrointestinal bleeding with a primary success rate of 94% (1144/1212). Compared to surgical results a reduction in mortality rate has been achieved. These results have been confirmed worldwide in routine clinical application and in controlled trials with selected patients. Potential bleeding lesions such as Osler haemangiomas and angiodysplasias can be sealed. Recanalization of inoperable obstructed oesophageal and gastric carcinoma by laser vaporization to relieve dysphagia and subsequently endoscopic iridium after loading irradiation show a medium survival time of 7.4 months. Preoperative recanalization of obstructed colorectal carcinoma to relieve ileus or subileus allows preoperative peroral bowel lavage and total colonoscopy to find synchronous cancers and polyps and to perform primary resections without intraoperative colon lavage. Sessile benign neoplastic polyps can be resected curatively by Nd:YAG laser vaporization. Recanalization of peptic stenosis and anastomotic scar stenosis can be performed.

Endoscopy↗
PubMed2006

Initial clinical experience with matrix detachable coils for the treatment of intracranial aneurysms.

OBJECT: The Matrix detachable coil is a new bioactive, bioabsorbable coil used in the endovascular embolization of intracranial aneurysms. It has a platinum core covered with a bioactive, bioabsorbable polymer (polyglycolic acid/lactide). The authors report on their initial midterm clinical experience with the first-generation Matrix detachable coil. METHODS: One hundred twelve patients harboring 118 aneurysms were treated using Matrix coils. Forty-nine aneurysms (41.5%) were associated with acute subarachnoid hemorrhage (SAH). Twenty-four lesions (49%) were harbored by patients with Hunt and Hess Grade I, 11 (23.4%) by patients with Grade II, eight (16.3%) by those with Grade III, and six (12.2%) by those with Grade IV. Four aneurysms (3.4%) were harbored by patients who had presented with nonacute SAH. Sixty-five aneurysms (55%) were unruptured. Fifty-seven lesions (48.3%) were small with a small neck, 29 (24.6%) were small with a wide neck, 30 (25.4%) were large, and two (1.7%) were giant. All patients were followed up to obtain angiography and clinical outcome data. Technical complications occurred in six patients: two thromboembolic complications and four aneurysm perforations. Of these six patients, the status of two deteriorated because of aneurysm perforation and another two because of thrombus formation (morbidity 3.6%). There were five deaths--one due to rerupture after embolization. Angiography follow-up studies of 87 aneurysms were obtained. Seventy aneurysms demonstrated progressive occlusion or a stable neck (80.5%), and 17 had some degree of recanalization (19.5%). The aneurysms originally diagnosed as a neck remnant showed a 15% rate of recanalization. CONCLUSIONS: Matrix coils can be delivered into aneurysms with technical complications similar to those encountered using GDCs. Midterm anatomical outcomes to date have shown moderate improvement in the recanalization rate when compared with those realized using the GDC system. Because of the increased friction associated with the first-generation Matrix coil, the packing density in most aneurysms was less than that achieved with GDCs. Prolonged angiography follow-up evaluations are needed to document long-term efficacy.

Absorbable Implants↗
PubMed2004

Comparison of long-term effects between intra-arterially delivered ethanol and Gelfoam for the treatment of severe arterioportal shunt in patients with hepatocellular carcinoma.

AIM: To evaluate long-term effect of ethanol embolization for the treatment of hepatocellular carcinoma (HCC) with severe hepatic arterioportal shunt (APS), compared with Gelfoam embolization. METHODS: Sixty-four patients (ethanol group) and 33 patients (Gelfoam group) with HCC and APS were respectively treated with ethanol and Gelfoam for APS before the routine interventional treatment for the tumor. Frequency of recanalization of shunt, complete occlusion of the shunt, side effects, complications, and survival rates were analyzed between the two groups. RESULTS: The occlusion rate of APS after initial treatment in ethanol group was 70.3%(45/64), and recanalization rate of 1 month after embolization was 17.8%(8/45), and complete occlusion rate was 82.8%(53/64). Those in Gelfoam group were 63.6%(21/33), 85.7%(18/21), and 18.2%(6/33). There were significant differences in recanalization rate and complete occlusion rate between the two groups (P<0.05). The survival rates in ethanol group were 78% at 6 months, 49% at 12 months, 25% at 24 months, whereas those in Gelfoam group were 58% at 6 months, 23% at 12 months, 15% at 24 months. The ethanol group showed significantly better survival than Gelfoam group (P<0.05). In the ethanol group, there was a significant prolongation of survival in patients with monofocal HCC (P<0.05) and Child class A (P<0.05). There were no significant differences in survival rate in the Gelfoam group with regard to the number of tumor and Child class (P>0.05). The incidence rate of abdominal pain during procedure in ethanol group was 82.8%. There was no significant difference in postembolization syndromes between two groups. Procedure-related hepatic failure did not occur in ethanol group. CONCLUSION: Ethanol embolization for patients with HCC and severe APS is efficacious and safe, and may contribute to prolongation of the life span versus Gelfoam embolization.

Arteriovenous Fistula↗
PubMed2002

Residual venous thrombosis as a predictive factor of recurrent venous thromboembolism.

BACKGROUND: The optimum duration of anticoagulant therapy after an episode of deep venous thrombosis (DVT) is controversial. Contributing to the controversy is uncertainty about whether residual venous thrombosis, as assessed by repeated ultrasonography over time, increases the risk for recurrent thromboembolism. OBJECTIVE: To determine the risk for recurrent thromboembolism in patients who have persistent residual thrombosis compared with patients who have early vein recanalization. DESIGN: Prospective cohort study. SETTING: A university hospital in Padua, Italy. PATIENTS: 313 consecutive symptomatic outpatients with proximal DVT who received conventional short-term anticoagulation. MEASUREMENTS: Ultrasonographic assessment of the common femoral and popliteal veins was performed 3 months after acute DVT in all patients and at 6, 12, 24, and 36 months in patients found to have residual venous thrombosis. Veins were considered recanalized if they were 2.0 mm or less in diameter on a single test or 3.0 mm or less in diameter on two consecutive tests. Recurrent thromboembolism was assessed during a 6-year period. RESULTS: The cumulative incidence of normal results on ultrasonography was 38.8% at 6 months, 58.1% at 12 months, 69.3% at 24 months, and 73.8% at 36 months. Of 58 recurrent episodes, 41 occurred while the patient had residual thrombosis. The hazard ratio for recurrent thromboembolism was 2.4 (95% CI, 1.3 to 4.4; P = 0.004) for patients with persistent residual thrombosis versus those with early vein recanalization. CONCLUSIONS: Residual venous thrombosis is an important risk factor for recurrent thromboembolism. Ultrasonographic assessment of residual venous thrombosis may help clinicians modify the duration of anticoagulation in patients with DVT.

Adult↗
PubMed1999

Intra-arterial cerebral thrombolysis for acute ischemic stroke in a community hospital.

BACKGROUND AND PURPOSE: Advances in thrombolytic therapy, brain imaging, and neurointerventional techniques provide new therapeutic options for acute stroke. Intra-arterial thrombolysis has proved to be a potent therapeutic tool. To show that this procedure can be performed in community hospitals, we describe our experience with a group of 11 patients treated for middle cerebral artery occlusions. METHODS: Twenty-two patients seen during a period of 1 year with clinical findings of acute major-vessel stroke met screening criteria and were evaluated under an institutional review board-approved protocol. After CT scanning, 17 of those patients met strict criteria, gave informed consent, and underwent angiography. Eleven patients had M1 and M2 middle cerebral artery occlusions and received local thrombolytic therapy with urokinase. Recanalization efficacy, complications, and outcome data were compiled. RESULTS: The average score on the National Institutes of Health Stroke Scale was 22.2 at the onset of treatment and 12.5 after therapy, with 91% of patients showing neurologic improvement. Complete (TIMI 3) recanalization occurred in 73% of cases and partial recanalization (TIMI 2) in 18%. At the 90-day follow-up evaluation, 56% of patients had good outcomes (modified Rankin score, 0 to 1). One intracranial hemorrhage occurred. CONCLUSION: Intra-arterial thrombolysis can be performed in a community hospital by radiologists with interventional and neuroradiologic skills given appropriate institutional preparation.

Aged↗
PubMed1999

Preinfarction angina and improved reperfusion of the infarct-related artery.

Preinfarction angina and early reperfusion of the infarct-related artery are major determinants of reduced infarct-size in patients with acute myocardial infarction. The beneficial effects of preinfarction angina on infarct size have been attributed to the development of collateral vessels and/or to post-ischemic myocardial protection. However, recently, a relation has been found between prodromal angina, faster coronary recanalization, and smaller infarcts in patients treated with rt-PA: those with preinfarction angina showed earlier reperfusion (p = 0.006) and a 50% reduction of CKMB-estimated infarct-size (p = 0.009) compared to patients without preinfarction angina. This intriguing observation is consistent with a subsequent observation of higher coronary recanalization rates following thrombolysis in patients with prodromal preinfarction angina compared to patients without antecedent angina. Recent findings in dogs show an enhanced spontaneous lysis of platelet-rich coronary thrombi with ischemic preconditioning, which is prevented by adenosine blockade, suggesting an antithrombotic effect of ischemic metabolites. Understanding the mechanisms responsible for earlier and enhanced coronary recanalization in patients with preinfarction angina may open the way to new reperfusion strategies.

Angina Pectoris↗
PubMedDate not supplied

[Radiographic-endoscopic diagnosis and treatment of obliterations of the upper urinary tract].

Potentialities of x-ray endoscopic diagnosis and treatment of upper urinary tracts (UUT) obliterations were studied in 26 and 21 patients, respectively. The causes of obliteration were previous urological, surgical, gynecological operations, radiotherapy (one case). Percutaneous or transurethral UUT recanalization was performed in 5 and 16 patients, respectively. The length of the obliteration varied from 0.3 to 1.7 cm. It was located at the level of ureteropelvic segment in 13(62%), in the upper third of the ureter in 4(19%) and in the lower third of the ureter in 4(19%) patients. UUT endoscopic recanalization was successfully performed in 17(81%) patients. The operation took 60-90 minutes. Minor complications were corrected conservatively. Control examination was made after 6 to 15 years follow-up. The result was assessed as positive in the absence of clinical symptoms, recurrent stricture(obliteration), in improvement or no change in renal function. These criteria were met in 14(66.7%) patients. One patient has undergone nephrectomy because of highly deficient renal function and dislocation of the nitinol spiral outside recanalization zone. Two patients live with drained kidney in spite of UUT restored patency. The method proved effective and can be used as first-line therapy in short obliteration (< 1 cm), relatively intact renal function and in the absence of UUT marked hypotonia, more so as the failure does not complicate further surgery. Combined x-ray endoscopic diagnosis is presently most significant in determination of complete stricture(obliteration) of ureteropelvic segment and the ureter, its length and location.

Adolescent↗
PubMedDate not supplied

Microwave coagulation versus insertion of a second stent for occluded biliary metal stent.

BACKGROUND/AIMS: There is no consensus regarding optimal management of self-expandable metallic stent occlusion. We investigated the efficacy of microwave coagulation therapy for recanalization as compared to second stent placement. METHODOLOGY: Sixty patients with malignant obstruction of the common bile duct were treated with metal stent placement from January 1992 to July 1999. Of these, 13 patients subsequently developed stent occlusion due to tumor ingrowth. We compared stent patency and patient survival rates after microwave coagulation to those after insertion of a second stent. The influence of the duration of patency of the first stent on the second stent patency was also evaluated. RESULTS: Of the 13 patients with stent occlusion, 7 were treated with microwave coagulation therapy, and 6 with insertion of a second metal stent. In all cases, occluded stents were successfully recanalized without any complications. There was no significant difference in duration of first stent patency between the two groups. The median duration of second stent patency was prolonged in microwave-treated patients (152 days vs. 104 days, P > 0.05). The median duration of patient survival after last recanalizing procedure was also prolonged in microwave-treated patients (131 days vs. 78 days, P > 0.05). Microwave energy did not induce destruction of the stent filament. CONCLUSIONS: Microwave coagulation did not offer significantly longer duration of stent patency and patient survival compared to insertion of a second metal stent. However, this procedure is safe, feasible, and certainly as good as a second stent placement. It may be an alternative to insertion of a second stent within the occluded stent.

Aged↗
PubMed2002

Combined direct percutaneous transluminal angioplasty and low-dose native tissue plasminogen activator therapy for acute embolic middle cerebral artery trunk occlusion.

BACKGROUND AND PURPOSE: In embolic middle cerebral artery (MCA) trunk occlusion, recanalization with direct percutaneous transluminal angioplasty (PTA) may be preferable to time-consuming thrombolysis. However, distal embolization with small crushed fragments is a complication of direct PTA. We prospectively evaluated combined direct PTA and low-dose native tissue plasminogen activator (t-PA) therapy for acute embolic MCA trunk occlusion. METHODS: Fifteen patients underwent direct PTA. The embolus was successfully crushed in 12, who received subsequent native t-PA infusion. Direct PTA was performed with a balloon catheter, which was advanced into the occlusion site and inflated several times until recanalization was established. After PTA, 7.2 mg of native t-PA in 100 mL of isotonic sodium chloride solution was infused for 30 minutes. Neurologic status was evaluated at admission and immediately and 1 month after treatment. In all patients, follow-up CT was performed within 24 hours and 3-7 days after onset, and follow-up MR imaging, 1 month after onset. RESULTS: Direct PTA failed to crush the embolus in three of 15 patients; these three had no clinical improvement. In 11 of 12 patients, combined therapy was successful, with no technical complication. Although no symptomatic intracerebral hemorrhage occurred, one patient had a small hematoma. All patients with successful recanalization had marked clinical improvement. Although angiograms showed distal embolizations in 10, cortical infarctions were confirmed in only three at follow-up. CONCLUSION: Combined direct PTA and IV low-dose native t-PA therapy may be a safe alternative to thrombolytic therapy in some patients with embolic MCA trunk occlusion.

Aged↗
PubMed2000

Possibilities and limits of minimal invasive lacrimal surgery.

Endoscopy of the lacrimal drainage system with miniaturized endoscopes has been possible since 1990 and permits the direct evaluation of the lacrimal drainage system. Additionally, attached instruments permit recanalization in cases of stenosis of the lacrimal drainage system. Both an Erbium-Yag Laser and a miniaturized drill are available, with which a stenosis of the lacrimal drainage system can be opened under endoscopic control. Favorable findings for endoscopic recanalization are stenoses in the area of the canaliculi or the lacrimal sac, for which the success rate of recanalization is approximately 75%. Unfavorable prognostic factors are submucous scar formations due to a dacryocystitis in the patient's history. Endoscopic findings have also improved the understanding of diseases of the lacrimal drainage system. Punctal stenoses causing epiphora often show intact mucous membranes before and behind the stenosis and it is possible to cure these patients without extensive surgical procedures. Micro-surgical procedures and dacryocystorhinostomy complete the spectrum of the endoscopic surgical possibilities in the lacrimal drainage system.

Journal Article↗
PubMed2002

Coronary arteriovenous fistula in pediatric patients: a 17-year institutional experience.

BACKGROUND AND PURPOSE: Coronary arteriovenous fistula (CAVF) is a rare congenital anomaly in pediatric patients. Its clinical manifestations vary considerably and its long-term outcome is not fully understood. This study sought to determine the natural history and long-term outcome in CAVF patients treated over a 17-year period at Cathay General Hospital in Taipei. MATERIALS AND METHODS: The medical records of all 10 pediatric patients (five boys and five girls aged between 15 days and 15 years) with CAVF treated from 1983 through 2000 at our hospital were reviewed. Data collected included symptoms and signs, the findings of electrocardiography, echocardiography, catheterization, and angiography, and surgical results. RESULTS: CAVF was diagnosed on the basis of color Doppler echocardiography in eight patients and by cardiac catheterization and angiography in two. Congestive heart failure was found in four patients and both myocardial ischemia and infarction were found in two patients. Most of the affected coronary arteries were tortuous and dilated with a mean diameter of 12.6 mm (range 5-40 mm). Under cardiopulmonary bypass, fistulous terminations were sutured in seven patients, three of whom were found to have multiple fistulous openings. Postoperative follow-up examinations revealed that all of the affected coronary arteries and fistulas remained dilated and tortuous, except in one patient. Two patients who had distal CAVF developed coronary thrombus, calcification, and ventricular aneurysm at 2 and 10 years after operation, respectively. Another patient developed fistulous recanalization 7 years after operation, but this abnormal channel had disappeared again 3 years after recanalization. One patient developed an iatrogenic CAVF 8 years after surgical repair of tetralogy of Fallot. CONCLUSIONS: Unlike adults, pediatric patients with CAVF tend to be symptomatic. Ligation of the fistulous termination alone does not reduce the size of the fistula. Our findings indicate that long-term follow-up is essential due to the possibility of postoperative recanalization, persistent dilation of the coronary artery and ostium, thrombus formation, calcification, and myocardial infarction. In addition, postoperative antiplatelet therapy is recommended, especially in patients with distal CAVF and abnormally dilated coronary arteries.

Adolescent↗
PubMed2002

Third generation thrombolytics for the treatment of ischemic stroke.

The field of intravenous and intra-arterial thrombolysis for the treatment of acute ischemic stroke is rapidly advancing. Limitations of existing thrombolytic agents have prompted the development of new thrombolytic agents over the last decade. These new agents are broadly classified as third generation thrombolytics. Two of the several third generation thrombolytic agents have been investigated for the treatment of acute ischemic stroke and include tenecteplase (Genentech Inc) and reteplase (Roche Holding AG). By virtue of structural modifications, third generation thrombolytics have longer half-lives and greater penetration into the thrombus matrix. Tenecteplase has been evaluated in experimental models of ischemic stroke. These experimental studies have observed faster and more complete recanalization of occluded arteries compared with second-generation thrombolytics. The first prospective human clinical trial evaluated the safety and efficacy of intra-arterial reteplase in 16 patients with ischemic stroke who were poor candidates for intravenous alteplase therapy. Near complete or complete recanalization was observed after treatment in 88% of the patients. The development and use of third generation thrombolytics is expected to increase the rate of recanalization and clinical recovery in patients with ischemic stroke. Clinical trials are required to determine the appropriate dose and patient selection for these emerging pharmacological agents.

Animals↗