[Evidence-based recommendations on primary diagnostics of peripheral arterial occlusive disease in geriatric patients]. / Evidenzbasierte Empfehlungen zur Basisdiagnostik der peripheren arteriellen Verschlusskrankheit bei geriatrischen Patienten.

The prevalence of peripheral arterial occlusive disease (PAOD) is high in elderly patients and its clinical manifestation is often atypical. Comorbidity and morbidity as a consequence of PAOD are significant. Therefore, standardized primary diagnostics are required among geriatric patients. Drawn from a search of the literature, evidence-based recommendations are provided. Pulse palpation and the evaluation of a patient's medical history are obligatory components of primary diagnostics, even in the absence of typical symptoms. In the case of pathological and ambiguous findings, measuring Doppler ankle pressures is suggested as the next diagnostic step. Further measures depend on the following factors: the presence of lesions on the leg with disturbed blood flow, predominantly in the foot and lower leg areas, degree of PAOD-related ailments, and, finally, intended surgery of the affected leg for other medical reasons.

Fibrinolytic treatment with ultra-high streptokinase infusion via the dorsalis pedis vein offers no advantage over systemic infusion via the brachial vein in patients with deep vein thrombosis of the leg.

The present study into the fibrinolytic therapy of deep vein thrombosis (DVT) considers whether streptokinase infusion into the dorsalis pedis vein of the affected leg (ipsipedal infusion) yields higher lysis rates than systemic infusion via the brachial vein (systemic infusion). In both cases the dosage regimen selected was a short-term ultra-high streptokinase (UHSK) infusion of 1.5 million IUSK/hour over a period of 6 hours (total SK dose: 9 million IU). A series of one to three UHSK infusions was given on one to three consecutive days. Forty patients were randomised to either systemic (Group S) or ipsipedal (Group IP) treatment. The distribution of important parameters determining a fibrinolytic response (e.g. the age, site and extent of DVT, and number of UHSK infusion series) was virtually identical in the two treatment groups. The rates for total and partial thrombolysis in the systemic infusion group were 50% and 10% respectively compared with 30% and 20% respectively in the ipsipedal group. The distribution of side-effects was approximately identical in the two groups. The results show that ipsipedal UHSK lysis via the dorsalis pedis vein confers no advantage over systemic infusion via the brachial vein.

Lysis block treatment: a new form of local thrombolysis.

Lysis block treatment (LBT) is a new form of fibrinolytic therapy for deep vein thrombosis and arterial occlusion in the distal parts of the limbs. Strictly local lysis was achieved by placing a cuff around the thigh or the upper arm, inflating the cuff to a pressure of 500 mmHg ("Bier's blockade"), and giving heparin and tissue plasminogen activator (rt-PA) by intravenous injection into the dorsal pedis or antecubital veins. Occlusion lasted for one hour. This new technique was demonstrated in 22 patients. Six patients presented with popliteal vein thromboses and 1 patient with a distal femoral vein thrombosis. In addition, 15 arterial occlusions were treated comprising 3 calf, 6 popliteal, 3 distal femoral, and 2 digital sites and 1 brachial site. Five of 7 venous and 9 of 15 arterial occlusions were partially or totally removed. The activated partial thromboplastin time remained nearly unchanged during LBT and only a limited and short-term lengthening was recorded after restoration of blood flow. This was of importance for patients with bleeding tendencies, which are normally a contraindication for systemic lysis. LBT may therefore be considered as a useful alternative to systemic fibrinolytic treatment.

[Lysis block technique--a new method of fibrinolytic treatment with tissue-type plasminogen activator (rt-PA)]. / Lyseblock-Technik--eine neue Methode der fibrinolytischen Behandlung mit Gewebeplasminogen-Aktivator (rt-PA).

With lysis-block technique an over-systolic tourniquet is put on the thigh or upper arm. The fibrinolytic substance is injected into a dorsal foot vein or forearm vein. By using this strictly local lysis it was possible to remove distal venous and arterial occlusions. During over-systolic blockade there was only a minimal link between the blocked part of the limb and systemic circulation. By choosing a lytic substance with a short half-life-period (rt-PA) the systemic effect after loosening the blockade was small. LBT is a new and interesting method for the fibrinolytic treatment of peripheral venous and arterial occlusions. The procedure is characterized by minimal systemic reactions and it can probably be applied in those patients with contraindications for systemic lysis.

[Regional drug-induced sympathicolysis in patients with arterial occlusive disease]. / Die regionale medikamentös induzierte Sympathikolyse bei Patienten mit AVK.

Regional drug-induced sympathectomy is a modification of Bier's block technique. By applying this method skin perfusion in patients with occlusions of lower leg arteries or functional disturbance of peripheral circulation can be improved. Under optimal technical conditions effects of regional and surgical sympathectomy are comparable. Fluorescence angiography can be applied to assess the effectiveness of drug-induced as well as surgical sympathectomy.

[Lysis block technique. Local fibrinolytic treatment of venous and arterial occlusions]. / Lyseblocktechnik. Lokale fibrinolytische Behandlung von Venen- und Arterienverschlüssen.

With lysis-block technique an oversystolic tourniquet is put on the thigh or upper arm. The fibrinolytic substance is injected into a dorsal foot vein or forearm vein. By using this strictly local lysis it was possible to remove distal venous and arterial occlusions. During oversystolic blockade there was only a minimal link between the blocked part of the limb and systemic circulation. By choosing a lytic substance with a short half-life-period (rt-PA) the systemic effect after loosening the blockade was small. LBT is a new and interesting method for the fibrinolytic treatment of peripheral venous and arterial occlusions. The procedure is characterized by minimal systemic reactions and it can probably be applied in those patients with contraindications for systemic lysis.

[Thrombolysis-block technique--a new local form of treatment of distal venous and arterial occlusions of the leg]. / Lyseblock-Technik--eine neue lokale Behandlungsform von Unterschenkelvenen- und-arterienverschlüssen.

Lysis-block technique is a new treatment form for deep vein and arterial thrombosis. A strictly local lysis is achieved by using "BIERS blockade" combined with a peripheral intravenous injection of the lytic substance. The new technique is demonstrated on four patients. Two patients had popliteal vein thrombosis. One patient was treated with urokinase. The other patient (unsuccessfully) with urokinase and (subsequently) successfully with rt-PA. In both cases full recanalization of the vessels was achieved. Two patients had occlusions of lower leg arteries. Clinically and angiographically perfusion could be distinctively improved by fibrinolytic treatment with urokinase. Analysis of fibrinogen and plasminogen levels showed no systemic fibrinolytic effect. This was of importance in one patient with a meningioma and in another patient with peptic ulcers of the stomach where otherwise no fibrinolysis would have been possible. Thus, lysis-block-therapy is an important new alternative to systemic fibrinolytic treatment especially in those patients with contraindications for systemic lysis.

[Circulatory changes with urapidil (Ebrantil) in general and regional anesthesia. Studies with normo- and hypertensive patients]. / Kreislaufveränderungen unter Urapidil (Ebrantil) in Allgemein- und Regionalanaesthesie. Untersuchungen mit normo- und hypertensiven Patienten.

Urapidil (Ebrantil) is a new antihypertensive agent exerting central and peripheral action which is recognized for the treatment of both chronic and acute hypertension. The purpose of the present study was to investigate the extent of the antihypertensive effect of urapidil in various forms of general or regional anaesthesia. To this end, a retrospective analysis was first carried out on the typical reactions of the circulatory system in 200 patients during either neuroleptanalgesia with diazepam and droperidol, or halothane, enflurane or intrathecal local anaesthesia. In a prospective study, each of 5 normo- or hypertensive patients undergoing elective surgery with one of the aforementioned anaesthetic procedures received 50 mg urapidil intravenously 25-30 min after start of anaesthesia. Blood pressure and heart rate measurements were performed for up to 24 h after the injection. Whereas anaesthesia alone caused a moderate drop in systolic and diastolic blood pressure of 3.1 and 2.1%, respectively (in normotensive patients), and of 12.0 and 6.7%, respectively (in hypertensive patients), urapidil caused a further significant fall in blood pressure in the hypertensive patients within a few minutes, but not in the normotensive groups. This effect was particularly pronounced under spinal anaesthesia and usually persisted until the end of the operation. Heart rate was (not significantly) increased for a few minutes after administration of urapidil. Temporary blood pressure reduction to hypotensive values was observed in 2 of the 50 patients only. From the results it is concluded that urapidil is an effective and relatively safe drug for the treatment of elevated blood pressure during routine surgery. Even if it has been administered on the basis of wrong indication (e.g. hypertensive phases as a result of insufficient anaesthesia), it rarely will cause blood pressure to fall to undesired low levels after anaesthesia has been normalized.