Administration of platelets to ruptured abdominal aortic aneurysm patients before open surgery: a prospective, single-blinded, randomised study.

BACKGROUND: In patients undergoing open surgery for a ruptured abdominal aortic aneurysm (rAAA), survivors demonstrate a high platelet count, and proactive administration of platelets (and fresh frozen plasma) appears to influence mortality. OBJECTIVES: This trial investigated the effect of platelets administered before transport to surgery. METHODS: In a prospective study design, patients were randomised to receive platelets (intervention; n = 61) or no platelets (control; n = 61) before transport to vascular surgery from 11 local hospitals. The study was terminated when one of the vascular surgical centres implemented endovascular repair for rAAA patients. RESULTS: Thirty days after surgery, mortality was 36% for patients with intervention vs 31% for controls (P = 0·32). Post-operative thrombotic events (14 vs 15; P = 0·69), renal failure (11 vs 10; P = 0·15) and pulmonary insufficiency (34 vs 39; P = 0·15) were similar in the two groups of patients. No adverse reactions to platelet administration were observed. In addition, length of stay in the intensive care unit was unaffected by intervention. CONCLUSIONS: For patients planned for open repair of a rAAA, we observed no significant effect of early administration of platelets with regard to post-operative complications and stay in the ICU or in hospital and also no significant effect on mortality.

Dacron or PTFE for above-knee femoropopliteal bypass. a multicenter randomised study.

OBJECTIVES: To compare polytetrafluorethylene (PTFE) and polyester grafts (Dacron) for above knee femoropopliteal bypass. DESIGN: Multicenter randomised clinical trial. MATERIAL AND METHODS: 427 patients were randomised between 6mm Dacron (Uni-Graft, B. Braun Melsungen AG, 34212 Melsungen, Germany) and PTFE (Goretex, W. L. Gore & Ass. Inc., Newark DE 19711, USA) above-knee femoropopliteal bypass grafts within 13 centres in Denmark (n=261), Norway (n=113) & Finland (n=53) between 1993 and 1998. Fourteen (3%) patients were excluded, leaving 413 patients with 208 Dacron and 205 PTFE grafts for analysis. Age, gender, indication (claudication: 65%), run-off (2 or 3 vessels: 76%), diabetes (17%) and hypertension (31%) as well as cerebrovascular (9%) and cardiac (33%) risks were evenly distributed. Patients were followed postoperatively at 1, 12 and 24 months. Patency assessment was based on ankle-brachial pressures or imaging in case of doubt. RESULTS: The two-year primary patency rates for Dacron and PTFE were 70% and 57% (p=0.02), whereas the secondary patency rates were 76% and 65% (p=0.04), respectively. Primary patency at two years was significantly influenced by the number of patent crural vessels (two or three 67%, one 50%, p=0.01). Amputations at two years, major in 4% and minor in 3%, 30-days mortality and complications (wound infections: 3% and other wound complications: 13%) occurred equally frequent in both groups. At two years, patients treated for critical limb ischemia had a major amputation more often than patients operated on for intermittent claudication, 10 and 3 respectively (p=0.003), and had higher mortality rates, 20% and 8% respectively (p=0.001). CONCLUSION: This trial confirms that Dacron is at least as durable as PTFE for above-knee bypass procedures, and might even be superior.

The efficacy of ultrasound-guided compression of iatrogenic femoral pseudo-aneurysms.

OBJECTIVE: to evaluate ultrasound guided compression (UGC) for the treatment of iatrogenic femoral pseudoaneurysms (PA). DESIGN: retrospective follow-up of 130 patients with suspected PA referred from the cardiac catheterisation laboratory over a 36-month period. RESULTS: the overall incidence of PA was 0.5% and was significantly higher after therapeutic (1.5%) than diagnostic (0.3%) procedures (p <0.000001). Forty-eight patients with a PA were treated with UGC with an 88% success rate. Success did not appear to be related to PA diameter. CONCLUSION: the efficacy of UGC as treatment of PAs is confirmed.

Early results of percutaneous transluminal angioplasty (PTA) of failing below-knee bypass grafts.

OBJECTIVES: An audit of treating femoro-crural bypass stenosis in the first instance by PTA. DESIGN: Prospective clinical pilot study in consecutive patients. MATERIALS: Prior to vascular bypass grafting all patients had critical ischaemia. Sixty-four PTA procedures in 50 grafts in 49 patients were carried out. Thirteen were in situ saphenous grafts, 16 were combined venous segments, 18 were combined PTFE and vein and three were PTFE only. METHODS: Conventional cross-over or antegrade PTA, eventually combined with local thrombolytic therapy. RESULTS: The nine-month assisted patency using PTA was 72%, following surgical repair in five cases after failed PTA the secondary patency was 86%. The amputation free survival rate was 88%. In 11 cases thrombosis was treated successfully with local thrombolysis. In two cases the balloon ruptured the native artery wall below the distal anastomosis with pseudoaneurysm formation. Six limbs were amputated during follow-up. The frequency of stenosis in combined grafts was significantly higher than in in situ vein grafts. CONCLUSION: Our results are comparable with surgery. About 600 hospital beds/days were saved. This shortened the time from the diagnosis of stenosis to therapy and shortened the waiting list for vascular surgery.

Comparison of efficacy in crossing femoropopliteal artery occlusions with movable core and hydrophilic guidewires.

PURPOSE: Compare the recanalization rate of femoropopliteal occlusions between movable core wire guide (MG) and hydrophilic guidewire (HG). METHODS: Conventional PTA technique was used, followed by enclosed thrombolysis. The MG was used for all patients in the first 2 years, the HG in the following 2 years. Baseline characteristics were similar for the two groups of patients. RESULTS: Recanalization of 124 femoropopliteal occlusions was attempted. Technical success was achieved with the MG in 45 of 59 procedures; 42 procedures were clinically successful. Using the HG, technical success was achieved in 35 of 65 procedures; clinical success was achieved in 35 of 65 procedures; clinical success was achieved in 29 cases (p < 0.0048). At 1-year follow-up, 32 extremities improved after treatment with MG and 22 extremities after treatment with HG (p < 0.035). CONCLUSION: The results suggest that the MG should be the first choice in recanalization of femoropopliteal occlusions.

Halving the number of leg amputations: the influence of infrapopliteal bypass.

A retrospective review of amputations in patients with vascular disease during 10 years in Bispebjerg Hospital was undertaken. There were 1383 amputations leading to 1167 final level amputations. In previously independent patients there were 482 below knee amputations (BKA), 476 above knee amputations (AKA) and 43 had disarticulations in the ankle, knee or hip. During the period studied the number of final level amputations in independent patients were halved from 122 in 1981 to 58 in 1990. A similar reduction was also found in the total number of amputations: from 171 to 90, and in the number of reamputations: from 35 to 21. However, amputations in patients from long stay institutions remained at a constant level by on average 17 per year. The decrease in amputation rate took place synchronously with an increasing use of bypass to crural and pedal arteries as well as an overall increase in vascular reconstructions and angioplasties of more than 100%. However, the BKA/AKA ratio decreased from 1.12 to 0.67 (p < 0.005).

[Surgical treatment of abdominal aorta aneurysm 1983-1987. A multicenter study. 1266 operations, development and early results]. / Operative behandling af abdominalt aorta-aneurysme 1983-1987. Multicenterundersøgelse. 1,266 operationer, udvikling og tidlige resultater.

During the years 1983-1987, 1,266 operations for abdominal aortic aneurysm (AAA) were carried out in eight surgical departments with vascular surgical function. The activity increased constantly corresponding to 311 patients in 1987 or 50% more than in 1983. During this period the distribution between patients subjected to elective operation and those operated upon as emergencies was very uniform. In the latter group, only a slight increase in the number of AAA patients with rupture was observed. The risk of complications was low with a significant decrease in the need for dialysis. The early mortality was constant for the patients subjected to elective operation remained constant about 5.5%. A marked decrease in the early mortality was observed for the patients operated upon as emergencies with rupture from 63 to 50% and without rupture from 37 to 25%. At the conclusion of the period, ultrasonic scanning became the preoperative investigation of election and introduction of an aortic prosthesis the method of operation of election. Patients with AAA should be recognized so that elective surgery can be offered before a condition endangering life develops.

Fibrinolysis and peptic ulcer.

The results here presented are well correlated to previous studies showing a low activity of plasminogen activator around an ulcer, but a high activity proximally to this has not been shown before, neither that the activity is dependent on the ulcer localization. The results show low fibrinolytic activity in the mucosa after treatment with cimetidine which has not before been observed. Theoretically these results could give an idea of better effect of antifibrinolytic treatment in patients with bleeding from duodenal ulcer.

Asymptomatic carotid lesions after endarterectomy of contralateral carotid artery. Five-year follow-up study and prognosis.

Of 185 patients who consecutively underwent carotid endarterectomy five years ago, 135 had a patent asymptomatic contralateral internal carotid artery (ICA). During follow-up (median, 59 months), 36 patients developed new neurologic symptoms (18 strokes and 18 transient ischemic attacks). Thirteen patients developed symptoms referable to the territory of the previously asymptomatic ICA (five strokes and eight transient ischemic attacks). Using life-table analysis, the annual stroke rate was estimated to be 1% and 2.2% considering the previously asymptomatic and symptomatic ICA, respectively. Separating patients according to the degree of stenosis on the preoperative angiogram and according to the presence of ulceration revealed a significantly higher incidence of neurologic events and strokes in patients with stenoses exceeding 50% and/or patients with obvious ulcerations. Although the risk of stroke without warning was increased in these subgroups, we did not consider the risk high enough to warrant prophylactic endarterectomy. An exception enough to warrant prophylactic endarterectomy. An exception may be the patient with a more than 90% stenosis.

Surgical treatment of anuria caused by renal artery occlusion. Case report.

A patient with anuria caused by renal artery occlusion is presented. Revascularization was performed 42 days after onset of renal failure, and resulted in complete normalization of kidney function. The case demonstrates that surgical treatment of prolonged renal artery occlusion with subsequent return of renal function is possible.

The antifibrinolytic properties of cimetidine.

The mucosal fibrinolytic activity was estimated in 24 patients with duodenal ulcer and in 11 patients with gastric ulcer. The fibrinolytic activity was estimated in biopsy specimens taken during gastroscopy. Specimens were taken in the corpus, in the antrum, and in the duodenal mucosa. In patients with duodenal ulcer the fibrinolytic activity was significantly higher in the corpus and antrum mucosa, whereas no difference was observed in the duodenal mucosa compared with controls. Gastric ulcer patients had, compared with controls, significantly higher activity in the corpus mucosa only. Fourteen patients with duodenal ulcer and five with gastric ulcer were treated with 1 g cimetidine daily for 4 weeks. The mucosal fibrinolytic activity was estimated before and after treatment in the above-mentioned regions. A significant reduction was observed after treatment in patients with duodenal ulcer, both in the corpus and in the duodenal mucosa, whereas no difference was seen in the duodenum. In patients with gastric ulcer a reduction was observed in the corpus mucosa only. The fibrinolytic activity estimated was plasminogen activator, and not other proteases, in all estimations.

Late results after surgical treatment of renovascular hypertension. A follow-up study of 122 patients 2-18 years after surgery.

During the period 1963-1980, 122 patients were operated on for renovascular hypertension at surgical department D, vascular section, Rigshospitalet, Copenhagen. Seventeen patients, with a median age of 24 years, had fibromuscular hyperplasia and 95 patients, with a median age of 48 years, had atherosclerosis. Twenty-four of the latter had bilateral renal artery lesions and 71 had unilateral disease. Ten patients had various other causes of renovascular hypertension. Operative mortality was 4.9%, decreasing to two per cent in the last 8 years. At discharge, 71% of the patients were normotensive without medication, 18% were improved, and 11% were unimproved. At follow-up in 1982, the actuarial 10-year survival rates for patients with unilateral and bilateral atherosclerotic disease were 65% and 48%, respectively. There was no difference between survival rates for patients with fibromuscular hyperplasia and an age- and sex-matched, population. Sixty-nine patients were reexamined with a median follow-up of 9 years. Of the survivors with atherosclerosis, 87% benefitted from the operation: 50% were normotensive without medication and 37% were improved. Of patients with fibromuscular hyperplasia, 93% benefitted from operation: 79% were normotensive and 14% were improved. The results support the value of surgery in patients with renal fibromuscular hyperplasia and to the long-term benefits of surgical treatment of patients with atherosclerotic renovascular disease.

Cimetidine--an antifibrinolytic agent?

The mucosal fibrinolytic activity was estimated in 14 patients with duodenal ulcer before and after 4 weeks' treatment with cimetidine. A significant reduction in fibrinolytic activity in the corpus and antrum mucosa was found after treatment. In patients with healed ulcer after treatment, the activity was lower than in patients with unhealed ulcers, but no significance was proved. Similarly, in five patients with gastric ulcer, reduction in fibrinolytic activity was found after cimetidine treatment but in the corpus mucosa only. The fibrinolytic activity in the mucosa is caused by plasmin. Whether this antifibrinolytic property of cimetidine is of any importance in the treatment of ulcer disease is still unknown.