Clinical relevance of musical murmurs in color-coded duplex sonography of peripheral and visceral vessels.

BACKGROUND: Musical murmurs (MMs) are Doppler phenomena which sound like high-frequency musical sounds. They reflect high and turbulent flow within relevant stenoses and were first described in degenerated bioprosthetic valves and later in intracranial vessels and were associated either with high-grade arterial stenosis, small collateral arteries or carotid cavernous fistulas. Objective of this article is to illustrate the spectrum of imaging of MMs observed in renal, intestinal and peripheral vessels. PATIENTS AND METHODS: Four experienced vascular ultrasound laboratories had been asked to report their cases with documented musical tones in color coded duplex sonography (CCDS) within a two year observational period (2008 and 2009). Documented Doppler findings and corresponding clinical data were analyzed. RESULTS: MMs were found in 18 patients with an incidence of 0.05 % and were observed in high grade stenosis in hemodialysis access (n = 5), in post-biopsy arteriovenous fistulas after renal transplantation (n = 3), in renal transplant artery (n = 1) and vein (n = 3), stenoses in peripheral (n = 2) and intestinal arterial disease (n = 2), and in peripheral veins (n = 2). CONCLUSIONS: The so called musical murmurs are a rare but potentially relevant finding in CCDS. They are caused by a variety of underlying pathologies with different clinical implications, however correct interpretation is mandatory since urgent therapy might be necessary.

Successful treatment of a mycotic pseudoaneurysm of the brachial artery with percutaneous ultrasound-guided thrombin injection and antibiotics.

We report the case of a 48 year old male with human immuno-deficiency virus and hepatitis C virus infection and previous grafting of a thoracic aortic aneurysm. He returned from a trip to India with fever and in a poor physical condition. Diagnostic work-up revealed septicaemia with staphylococcus aureus, infection of the aortic graft with covered rupture of the proximal anastomosis and mitral valve endocarditis. Following antibiotic therapy, implantation of a transcutaneous endovascular aortic prosthesis and mitral valve repair were performed. During the postoperative period, the patient complained of pain and a palpable pulsating mass in the right cubital fossa. Ultrasound scan revealed a pseudoaneurysm at the brachial artery bifurcation. Since there were no signs of venous puncture in this area, we assumed this to be a mycotic pseudoaneurysm resulting from septic embolism. In the absence of clinical signs of inflammation, this pseudoaneurysm was successfully treated by ultrasound-guided thrombin injection. Irrespective of the cause for this mycotic pseudoaneurysm of the brachial artery, percutaneous ultrasound-guided thrombin closure in combination with antibiotic therapy might be a feasible, safe, cheap and minimally-invasive alternative to surgery.

Spontaneous pseudoaneurysm of a femoro-popliteal Omniflow II graft treated with a stentgraft.

We report the case of a symptomatic spontaneous leak of a biosynthetic graft (Omniflow (II) treated endovascularly with a stentgraft. Potential degeneration of biosynthetic grafts with aneurysm formation is a well known problem with a reported incidence of up to 7 %. Implantation of a stentgraft for treatment of a pseudoaneurysm is a valuable treatment option in native arteries; however its use in Omniflow II bypass grafts has not been reported so far. Surveillance of peripheral bypass grafts with duplex ultrasound may be helpful to detect morphological alterations of the graft.

Targeted mutation of plakoglobin in mice reveals essential functions of desmosomes in the embryonic heart.

Plakoglobin (gamma-catenin), a member of the armadillo family of proteins, is a constituent of the cytoplasmic plaque of desmosomes as well as of other adhering cell junctions, and is involved in anchorage of cytoskeletal filaments to specific cadherins. We have generated a null mutation of the plakoglobin gene in mice. Homozygous -/- mutant animals die between days 12-16 of embryogenesis due to defects in heart function. Often, heart ventricles burst and blood floods the pericard. This tissue instability correlates with the absence of desmosomes in heart, but not in epithelia organs. Instead, extended adherens junctions are formed in the heart, which contain desmosomal proteins, i.e., desmoplakin. Thus, plakoglobin is an essential component of myocardiac desmosomes and seems to play a crucial role in the sorting out of desmosomal and adherens junction components, and consequently in the architecture of intercalated discs and the stabilization of heart tissue.

Giant arteriovenous fistula after implantation of a percutaneous left ventricular assist device.

INTRODUCTION: Percutaneous left ventricular assist devices are an important tool in the management of patients with severe cardiogenic shock. Limited experiences concerning vascular complications after long term implantation of these devices exist. We report on a large arteriovenous fistula after placement of a left ventricular assist device, which has not been described in the literature. The arteriovenous fistula was of clinical relevance because it represented a supplementary cardiac burden in a patient with impaired left ventricular function after a severe myocardial infarction.

Intraoperative color duplex ultrasound during renal transplantation.

The purpose of this pictorial essay is to describe the role of intraoperative color duplex ultrasound in detecting vascular complications during renal transplantation. Intraoperative color duplex scanning during renal transplantation detects vascular complications noninvasively. Reasons for disturbed perfusion can be malposition or external compression, intravascular thrombi, vessel wall dissection and vasospasm. Color duplex ultrasound is a useful procedure in selected conditions with an intraoperatively suspected perfusion problem during renal transplantation.

Efficient haemodialysis despite complete central venous thrombosis.

Two cases with a fully functional haemodialysis access, in spite of complete thrombotic occlusion of the ipsilateral subclavian and/or brachiocephalic vein are reported. The coincidentally detected complete venous occlusions may indicate that occult venous stenosis or thrombosis is more frequent than generally assumed. In order to avoid deterioration of the haemodynamic situation interventions may be withheld unless clinical problems related to a diminished outflow occur.

Quality of life improvement after hospital- based rehabilitation or home-based physical training in intermittent claudication.

BACKGROUND: The magnitude of potential changes in Quality-of-Life (QoL) after structured institution-based or home-based peripheral arterial disease (PAD) rehabilitation programs are largely unknown at present. This pilot study provides first QoL data after PAD rehabilitation or a home-based PAD training. PATIENTS AND METHODS: In a non-randomized, open-label pilot study three groups of out-patients were compared: group 1 (n = 18) PAD rehabilitation; group 2 (n = 17) PAD rehabilitation + clopidogrel 75 mg once daily; group 3 (n = 20) home-based training. The training period was 3 months, which was followed by a 3-month observation phase (without prescribed training). The institution-based rehabilitation program consisted of 3 training hours per week whereas patients training at home were instructed to walk for 1 hour per day on an outdoor track. QoL assessment was performed using MOS SF-36, PAVK-86 and PAD-WIQ questionnaires. RESULTS: At baseline background variables, demographics and claudication distances were comparable between groups. After three months of training the percentage changes for the initial and the absolute claudication distance (ICD, ACD) for groups 1, 2, and 3 amounted to 164%, 201%, 44% (ICD) and 83%, 131%, 5% (ACD), respectively. Statistically significant QoL improvements were recorded for physical functions, pain and disease related anxiety in all three study groups; statistically significant inter-group differences were not found. CONCLUSIONS: In sharp contrast to the development of the claudication distances the improvement in QoL, found after 3 months of training, was comparable and not consistently different between the groups.

High Spatial Resolution Cardiovascular Magnetic Resonance at 7.0 Tesla in Patients with Hypertrophic Cardiomyopathy - First Experiences: Lesson Learned from 7.0 Tesla.

BACKGROUND: Cardiovascular Magnetic Resonance (CMR) provides valuable information in patients with hypertrophic cardiomyopathy (HCM) based on myocardial tissue differentiation and the detection of small morphological details. CMR at 7.0T improves spatial resolution versus today's clinical protocols. This capability is as yet untapped in HCM patients. We aimed to examine the feasibility of CMR at 7.0T in HCM patients and to demonstrate its capability for the visualization of subtle morphological details. METHODS: We screened 131 patients with HCM. 13 patients (9 males, 56 ±31 years) and 13 healthy age- and gender-matched subjects (9 males, 55 ±31years) underwent CMR at 7.0T and 3.0T (Siemens, Erlangen, Germany). For the assessment of cardiac function and morphology, 2D CINE imaging was performed (voxel size at 7.0T: (1.4x1.4x2.5) mm3 and (1.4x1.4x4.0) mm3; at 3.0T: (1.8x1.8x6.0) mm3). Late gadolinium enhancement (LGE) was performed at 3.0T for detection of fibrosis. RESULTS: All scans were successful and evaluable. At 3.0T, quantification of the left ventricle (LV) showed similar results in short axis view vs. the biplane approach (LVEDV, LVESV, LVMASS, LVEF) (p = 0.286; p = 0.534; p = 0.155; p = 0.131). The LV-parameters obtained at 7.0T where in accordance with the 3.0T data (pLVEDV = 0.110; pLVESV = 0.091; pLVMASS = 0.131; pLVEF = 0.182). LGE was detectable in 12/13 (92%) of the HCM patients. High spatial resolution CINE imaging at 7.0T revealed hyperintense regions, identifying myocardial crypts in 7/13 (54%) of the HCM patients. All crypts were located in the LGE-positive regions. The crypts were not detectable at 3.0T using a clinical protocol. CONCLUSIONS: CMR at 7.0T is feasible in patients with HCM. High spatial resolution gradient echo 2D CINE imaging at 7.0T allowed the detection of subtle morphological details in regions of extended hypertrophy and LGE.

The frequency of occurrence of anti-cardiac receptor autoantibodies and their correlation with clinical manifestation in patients with hypertrophic cardiomyopathy.

The purpose of this study was to investigate the frequency of occurrence of autoantibodies against G-protein coupled cardiovascular receptors and their relation to the clinical manifestation of hypertrophic cardiomyopathy (HCM). Autoantibodies against beta1-receptors, Muscarin-2-receptors, Angiotensin-II-receptor subtype 1 and alpha1-receptors were determined with ELISA in 52 patients with HCM (37 male, 15 female, mean age 55 +/- 15 years) and 40 healthy, age and sex matched controls. The clinical characterization of the HCM-patients included ECG, 24-h Holter, and echocardiography. The results showed that there is no significant difference in the frequency of a single autoantibody between HCM-patients and controls. However, if the number of patients who have autoantibodies against beta1-receptors and/or Muscarin-2-receptors were counted together, there are significantly more autoantibodies in HCM compared to controls (11 vs. 2, p = 0.035). Analysis of clinical data from this pooled group of patients showed that in patients with autoantibodies, heart rate variability (HRV), ultra low frequency (ULF) and very low frequency (VLF) were decreased (HRV by 20%, ULF by 50%, and VLF by 46%, p < 0.008) whereas the QTc-interval was increased by 8% (p < 0.02 each). The ratio of septal to posterior wall thickness was increased by 23% (p = 0.05), and the preejection period was prolonged by 46% in patients with autoantibodies (p < 0.001). These results suggest that the existence of these autoantibodies could be associated with an advanced stage or a severe manifestation of HCM.

Unusual cause of intermittent claudication.

Spontaneous dissection of a peripheral artery is a rare event. We report a case of a spontaneous, non-atherosclerotic and non-aneurysmal dissection limited to the external iliac artery in a 60-year-old woman who was admitted with a left calf claudication. Non-invasive examination documented signs of leg ischemia due to a floating wall dissection of the external iliac artery. After medical treatment over eight weeks the dissection membrane had been adapted to the vessel wall. A similar case of a spontaneous dissection limited to the external iliac artery, followed by a spontaneous healing has not been reported in the literature.

Symptomatic vascular complications after vascular closure device use following diagnostic and interventional catheterisation.

BACKGROUND: Haemostatic puncture closure devices for rapid and effective hemostasis after arterial catheterisation are a comfortable alternative to manual compression. Implanting a collagen plug against the vessel wall may become responsible for other kind of vascular injuries i.e. thrombotic or stenotic lesions and peripheral embolisation. The aim of this paper is to report our clinically relevant vascular complications after Angio-Seal and to discuss the results in the light of the current literature. PATIENTS AND METHODS: We report the symptomatic vascular complications in 17 of 7376 patients undergoing diagnostic or therapeutic catheterisation between May 2000 and March 2003 at the University Hospital Basel. RESULTS: Most patients presented with ischaemic symptoms, arterial stenoses or occlusions and thrombotic lesions (n = 14), whereas pseudoaneurysms were extremely rare (n = 3). Most patients with ischaemic lesions underwent vascular surgery and all patients with a pseudoaneurysm were successfully treated by ultrasound-guided compression. CONCLUSIONS: Severe vascular complications after Angio-Seal are rare, consistent with the current literature. There may be a shift from pseudoaneurysms to ischaemic lesions.

[Conservative management of thrombophlebitis. Cooling, wrapping and mobilizing the patient]. / Eine Thrombophlebitis bekommen Sie meist konservativ in den Griff. Kühlen, wickeln und den Patienten aus dem Bett holen!

As the name implies, thrombophlebitis superficialis affects superficial extrafascial veins, and is thus to be differentiated from phlebothrombosis (thrombosis in the deep venous system). Special manifestations are varicophlebitis arising out of a varicosis, thrombophlebitis migrans or saltans as recidivating inflammation of non-varicose veins, and the rare Mondor's disease. On the basis of the typical clinical presentation with tenderness, reddening and warming of the skin over the hardened (palpation) vein, thrombophlebitis is relatively easy to diagnose. In uncertain cases, duplex ultrasonography serves to exclude involvement of the deep venous system. The leading therapeutic measure is compression. Whenever possible, the patient should be mobilized. Cold dressings, anti-inflammatory medication and, if indicated, a stab incision, help ameliorate pain.

Non-invasive pressure measurement of the great saphenous vein in healthy controls and patients with venous insufficiency.

OBJECTIVES: Venous pressure measurement using an intravenous catheter is the sole method for the diagnosis of venous hypertension in patients with chronic venous insufficiency. A noninvasive tool to quantify increased venous pressure is essential for studying venous pathophysiology. Aim of the study was to investigate the value of controlled compression ultrasound (CCU) for noninvasive assessment of venous pressure (VP) of the great saphenous vein (GSV) in healthy persons and patients with venous insufficiency to quantify venous hypertension. METHODS: An optimal visible part of the GSV directly above the ankle was marked on the skin and compressed under ultrasound control and pressure needed for complete compression of the vein was recorded using a pressure manometer with a translucent silicone membrane. Complete insufficiency of the GSV (Hach IV) was documented by duplex ultrasound by an independent investigator before start of the study. VP measurement was performed while normal breathing, deep inspiration and expiration and during a standardized Valsalva maneuver. RESULTS: Twenty controls and 19 patients with complete insufficiency of the GSV were included. Valsalva maneuver induced a slight increase in VP in controls (20.1 ± 4.5 vs 25.1 ± 6.6 mbar) but a significant higher increase in patients from 26 to 37 mbar (IQR 18.5-28.0 vs 31.5-43.0; p < 0.001). CONCLUSION: Noninvasive venous pressure measurement of the great saphenous vein using CCU is feasible and documents an increased pressure during Valsalva maneuver in Hach IV patients compared to healthy controls.

Impact of endovascular treatment of atherosclerotic renal artery stenosis on endothelial function and arterial blood pressure.

AIM: Renovascular disease may cause arterial hypertension and decreases renal function, which both impair endothelial function. Endothelial function, a surrogate marker for cardiovascular risk, can be assessed non-invasively by ultrasound. The aim of this study was to investigate the impact of percutaneous transluminal renal artery angioplasty (PTRA) with stenting on endothelial function and arterial blood pressure in patients with renal artery stenosis (RAS). METHODS: Flow mediated dilatation of the brachial artery, flow velocities and shear stress were measured with high resolution ultrasound in 24 hypertensive patients with renal artery stenosis prior and one day after revascularization by PTRA with stenting. Endothelial-independent brachial dilatation was measured after application of nitroglycerin. RESULTS: Endothelial-dependent dilatation improved from 2.4±0.9% to 6.1±1.4% (P=0.03), whereas endothelial-independent dilatation did not change after PTRA. Endothelial-dependent reactive hyperemic blood flow increased from 195±40 mL/min to 536±94 mL/min (P=0.0008), whereas endothelial-independent hyperemia did not increase after revascularization. After PTRA, shear stress at rest decreased from 37±11 to 23±3 dyne/cm² (P<0.0001), and reactive hyperemic shear stress increased from 89±29 to 107±12 dyne/cm² (P=0.014). The impact of PTRA on arterial blood pressure resulted in a mean decrease of 21±5 mmHg in systolic pressure (P<0.0001), of 9±2 mmHg in diastolic pressure (P=0.03), and of 14±5 mmHg in peripheral pulse pressure (P=0.0003), respectively. CONCLUSION: Endovascular treatment of renovascular disease improves endothelial function and decreases in resting shear stress.

[Electric blue finger nail]. / Blauer Strom unter dem Fingernagel.

Glomus tumors are benign tumors and are most often localized acral. They usually are diagnosed non-invasively by patient's history, clinical examination, duplex ultrasound and MRI-angiography. Need for intervention depends on the symptoms.