MRI lesions after invasive therapy of carotid artery stenosis: a risk-modeling analysis.

BACKGROUND: Diffusion-weighted imaging (DWI) abnormalities can frequently be detected after carotid endarterectomy (CEA) and carotid angioplasty with stent placement (CAS) of the carotid arteries. We looked for possible predictors for the development of DWI lesions during the intervention. METHODS: We investigated 41 patients who underwent CAS without protection devices and 93 patients who underwent CEA. DWI studies were performed 1 day before and after the intervention. RESULTS: Ischemic complications consisted of two strokes (2.2%) in the CEA group and one stroke (2.4%) in the CAS group. DWI lesions were detected in 28.0% of all patients after intervention. Using a multivariate regression analysis, diabetes mellitus (DM), hyperlipidemia, symptomatic stenosis, age and CAS were found to be significant predictors for the occurrence of DWI lesions. CONCLUSIONS: DWI is an objective and highly sensitive method for monitoring interventions of the carotid arteries. Our results point to an increased risk of patients with diabetes and hyperlipidemia to develop DWI lesions during invasive therapy of the ICA.

[Interventional treatment of extracranial carotid stenoses: current status, requirements and indications]. / Positionspapier zur Indikation und Durchführung der interventionellen Behandlung extrakranieller Karotisstenosen.

Interventional treatment of extracranial carotid stenoses: current status, requirements and indications Around 30000 strokes per year in Germany are caused by extracranial obstructions of the carotid arteries. Besides the well established surgical endatherectomy, which has been proven to be superior to medical treatment alone in randomized multicenter trials, percutaneous treatment by balloon angioplasty and stent placement is increasingly performed. This consensus paper summarizes the present status of scientific studies and controlled treatment registries of carotid angioplasty and stenting and yields to recommendations regarding its performance and indication. A Medline search was done until August 2005 including all randomized comparative studies with clinical endpoints and all controlled registries with more than 500 patients included. Both completed randomized trials comparing angioplasty and stenting with surgery (CAVATAS and SAPPHIRE) did not show a significant difference with respect to stroke and death within 30 days. The incidence of this combined endpoint was between 3.3 and 6.9% in large multicenter registries. Thus, the current endovascular treatment results in a perlinterventional complication rate comparable to that which is commonly accepted for vascular surgery. A systematic preferably external quality monitoring as well as interdisciplinary cooperation most importantly with neurologists is recomendedfor all interventionalists. Based on available clinical data, this consensus paper defines recommendation classes I or II with a level of evidence B or C depending on symptoms, operative risk status of the patient and severity of the underlying stenosis.

Manual compression repair of post-catheterization femoral pseudoaneurysms: an alternative to ultrasound guided compression repair?

BACKGROUND: It is unknown, whether direct guidance by ultrasound is essential for the safety and efficacy of ultrasound-guided compression repair (UGCR) of pseudoaneurysms. We therefore tested, whether clinically guided manual compression repair (MCR) without continuous ultrasound control may represent an equally effective alternative. METHODS: After ultrasound diagnosis of a pseudoaneurysm, direct manual compression was applied to the lesion until the characteristic clinical signs disappeared or for a maximum of 1 hour. Then a compression bandage was applied for 24 hours. If the pseudoaneurysm persisted, MCR was repeated up to a maximum of three times. RESULTS: Of 96 consecutive patients with pseudoaneurysms, ten patients were referred to primary surgery; one patient refused any therapy. The remaining 85 patients (89%) were treated by MCR. MCR was successful in 74 patients (87%). Of these, 74% were cured at the first attempt, while 16% resp. 10% required 2 resp. 3 compression manoeuvers for definite cure. The success rate tended to be somewhat lower in patients on anticoagulants (78%) than in those on aspirin (91%) or those without any antithrombotic medication (89%) (p = 0.14). No major complications were observed. Of the 11 patients in whom MCR was unsuccessful, five patients underwent surgical repair; in four patients the pseudoaneurysms thrombosed spontaneously within 1-3 months and 2 pseudoaneurysms persist without complications. CONCLUSIONS: Our results with MCR are comparable to those published for UGCR. Since MCR requires less technical equipment and seems to be less painful for the patient, a prospective comparison of both methods appears warranted.

Initial experience with Healthport miniMax and other peripheral arm ports in patients with advanced gastrointestinal malignancy.

While central ports are located at the chest, peripheral ports (PP) are inserted at the patients' forearms. Two new PPs (Healthport miniMax((R)) and Bard Titan Low Profile Port) and two well-established types (Port-A-Cath((R)) P.A.S. Port and PeriPort(TM) peripheral access system) were tested. 125 patients were given the choice between PP and chest ports, and 100 of them chose PP. PP were inserted in patients suffering from gastrointestinal malignancies (n = 95), AIDS (n = 3) or Crohn's disease (n = 2). The first 30 patients were prospectively monitored by repeated color-coded duplex sonography examinations in order to evaluate clinically inapparent thromboses. Easy percutaneous needle puncture as early as 1 day after surgery was possible using innovative ports with large septa. The following complications arose during 12,688 catheter placement days: difficult implantation (n = 5), intolerable pain at the insertion site (n = 1), port erosion of the skin (n = 1), catheter leaks (n = 4), disconnection of the catheter from the port (n = 1), systemic infections (n = 4), local infections (n = 6) and symptomatic deep vein thrombosis (n = 8) despite anticoagulation in 1 of these. Only systemic infections and intolerable pain resulted in PP explantation (n = 5); other complications were easily dealt with. No serious or life-threatening complications occurred.

[Deep venous thrombosis caused by central venous catheter]. / Tiefe Venenthrombosen durch zentralvenöse Katheter.

Infections and venous thromboses are the major complications of central venous access catheters and ports. The frequency of thrombosis depends on the venous access systems used, their material, their diameters and the position of their tips. The lowest rate of thrombotic complications is seen with single or double lumen Hickman- or port catheters made of silicone with their tips in the lower half of the superior vena cava or in the right atrium. Antibiotics given preoperatively and heparin for at least 90 days after catheter placement must be recommended in oncological patients with a high risk of thrombosis. In case of thrombosis-related occlusion of the catheters low-dose urokinase and streptokinase can be helpful to restore the catheter's function. Else, therapy is identical to that of other types of thrombosis.

Management of 219 consecutive cases of postcatheterization pseudoaneurysm.

OBJECTIVES: We attempted to evaluate nonsurgical methods of treating postcatheterization pseudoaneurysm. BACKGROUND: The value of reapplication of a compression bandage, ultrasound-guided compression repair (UGCR) and awaiting spontaneous thrombosis in the treatment of postcatheterization pseudoaneurysms is unsettled. METHODS: We followed a stepwise treatment strategy of primarily conservative management using 1) reapplication of a compression bandage, followed by 2) UGCR, if needed, and 3) observation of the natural course. Surgical repair was reserved for patients with a rapidly expanding or complicated lesion. RESULTS: Reapplication of a compression bandage was performed in 128 patients and was successful in 32%. The success rate correlated inversely with anticoagulant therapy and the size of the aneurysm. In case of failure this pretreatment with a compression bandage significantly enhanced the success rate of subsequent UGCR (p = 0.04). UGCR was performed in 124 cases with a success rate of 84%. In 54 patients with a stable lesion, refraining from any (further) active measures resulted in spontaneous thrombosis of the aneurysm in 50 patients (93%) after 1 to 180 days (median 40 days). The course of the remaining four femoral artery aneurysms was uneventful. Definitive repair by operation or collagen plug implantation was required in only 20 patients (9%). CONCLUSIONS: The first measure performed in the treatment of pseudoaneurysms should be reapplication of a compression bandage, followed, if necessary, by UGCR. After failure of UGCR, spontaneous healing occurs in the majority of patients. Operation can be reserved for progressive and complicated lesions.

Treatment of deep vein thrombosis with low-molecular-weight heparins: a consensus statement of the Gesellschaft für Thrombose-und Hämostaseforschung (GTH).

Recent studies have led to a new concept for the management of deep vein thrombosis. The German Society on Thrombosis and Haemostasis decided to work up the clinical studies in this field published until June 1996 for a consensus statement. The consensus group concluded that (1) high-dose, APTT-controlled subcutaneous administration of unfractionated heparin is as effective as high-dose, APTT-controlled continuous intravenous infusion of unfractionated heparin (grade B recommendation); (2) the anticoagulation with heparin may start at day 1 or 2, overlapping with oral anticoagulants for 7 to 10 days (grade C recommendation); (3) high-dose subcutaneous low-molecular-weight heparins are almost as effective and safe as continuous intravenous infusion of unfractionated heparins (grade B recommendation); (4) no agreement was obtained for the other concomitant treatments of DVT, such as duration of bed rest, use of antiphlogistic drugs, whether LMW heparins are comparable, and whether outpatient treatment can be recommended using LMW heparins.

High-dose streptokinase therapy with three million units in one hour significantly improves early coronary patency rates in acute myocardial infarction.

In a prospective, randomized open trial, significantly higher patency rates were observed 60 minutes after beginning fibrinolytic therapy for acute myocardial infarction after administration of 3 million U streptokinase as compared to 1.5 million U (Thrombolysis in Myocardial Infarction [TIMI] grade 2 and 3 in 52% vs 26%; p = 0.04). Adverse events were observed with similar frequency in both groups.

[The effect of Taprostene on platelet activation and clinical course after percutaneous transluminal angioplasty]. / Der Einfluss von Taprosten auf Thrombozyten-aktivierung und klinischen Verlauf nach perkutaner transluminaler Angioplastie.

In a double blind pilot study, we examined the effects of the stable prostacyclin derivate taprostene compared to a combination of aspirin and dipyridamole on platelet uptake and clinical outcome after peripheral percutaneous angioplasty. Taprostene was administered to 19 patients as a continuous intravenous infusion from 2 hours before until 8 (n = 6) or 24 (n = 6) hours after angioplasty; 7 control patients were given a combination of 330 mg aspirin and 75 mg dipyridamole. Uptake of 111-indium labelled platelets at the site of the PTA was measured 3 hours before and 4 and 24 hours after angioplasty. Clinical parameters were obtained one day before PTA, on the following day and 3 months after the procedure. There was a tendency for slightly higher platelet uptake ratios in the taprostene groups as compared to the control group especially in patients requiring technically difficult procedures. There were no differences between the 3 groups with regard to primary success or periinterventional complications. In the taprostene patients, 3 early reocclusions were found up to 72 hours after the procedure and 1 late reocclusion within 3 months. In the control group, no reocclusion was apparent in the observation time. No advantages were found when taprostene was administered during angioplasty as compared to conventional treatment with aspirine and dipyridamole.

Efficacy and safety of collagen implants for haemostasis of the vascular access site after coronary balloon angioplasty and coronary stent implantation. A randomized study.

A vascular haemostasis device has recently been introduced that allows percutaneous implantation of collagen plugs for haemostatic sealing of puncture sites even under full anticoagulation. This study assessed the incidence of access site complications after collagen plug implantation in patients with percutaneous coronary angioplasty (PTCA) or coronary stenting. Seventy-eight patients with coronary stenting and 231 patients with PTCA were included in a prospective randomized trial comparing collagen plug implantation to conventional haemostasis. Collagen plug implantation significantly reduced median manual compression times from 45 min (quartiles: 35 min, 51 min) to 5 min (4 min, 6 min) after stenting (P = 0.001) and from 27 min (20 min, 32 min) to 5 min (4 min, 6 min) after PTCA (P = 0.0001). After stenting, in 15 of the 37 patients with collagen implants, access site complications occurred (11 pseudoaneurysms, one arteriovenous fistula, three bleedings requiring blood transfusion, four local infections). The complication rate in the control group (17/41) was not significantly different (P = 0.88). After PTCA, three of the 114 control group patients suffered access site complications, while in the corresponding treatment group of 117 patients, complications occurred in 16 (seven pseudoaneurysms, one arteriovenous fistula, six infections, two femoral occlusions, one bleeding with nerve compression; P = 0.0049). In conclusion, the vascular haemostasis device allows rapid sealing of the vascular access site even under full anticoagulation. Its use after PTCA was however associated with increased access site complications, particularly infections, and even after coronary stenting, failed to reduce the incidence of access site complications.

[Acute ischemia of an arm as an unusual manifestation of ergotism]. / Akute Ischämie eines Armes als ungewöhnlicher Ausdruck eines Ergotismus.

A 27-year-old woman developed acute pain, pallor and feeling of cold in her left arm. She had been a smoker of 15-20 cigarettes daily since the age of 15 years, but had not previously had any serious illness. In addition to contraceptives she had had been taking one to several suppositories containing caffeine and ergotamine tartrate (2 mg) daily against migraine. Angiological examination 5 days after onset of symptoms discovered a weak brachial pulse low in the left upper arm, while ulnar and radial pulses were absent. All other pulses were normally palpable. Colour duplex sonography demonstrated occlusion of the brachial artery which angiographically was due to a 5 cm severe narrowing without thrombus, blood flowing distally via collaterals. No improvement was achieved by local injection of 100,000 IU urokinase, 0.5 mg nitroglycerin, 20 mg tolazoline and a 3-hour infusion of alprostadil. On infusion of 560 ml hydroxyethylstarch over 8 hours, 400 mg naftidrofuryl, therapeutic doses of heparin and abstinence from ergotamine (since admission) the vessel diameter increased by 50% within 23 hours and after a further 24 hours to almost 100% of the comparable arterial segment of the right arm while merely on heparin infusion.

New aspects in ultrasound-guided compression repair of postcatheterization femoral artery injuries.

BACKGROUND: This study was undertaken to expand the understanding of ultrasound-guided compression repair (UGCR) of postcatheterization femoral artery injuries. METHODS AND RESULTS: In a series of 62 patients with pseudoaneurysms (n = 53) or arteriovenous (AV) fistulas (n = 9), UGCR was performed as a nonsurgical method in the treatment of postcatheterization femoral artery injuries. When the communicating channel could be visualized (43 cases), pressure was focused on it; otherwise (10 cases) the extraluminal cavity itself was compressed. In 45 cases, the elimination of flow in the pseudoaneurysm and/or the communicating channel could be achieved only with simultaneous temporary complete occlusion of the femoral artery. UGCR was successfully performed in 25 of 27 cases of false aneurysms (93%) in patients without anticoagulation and in 14 of 26 patients (54%) on anticoagulants. Three of 9 AV fistulas could be repaired by this method. No apparent correlation could be found between the therapeutic success and the size of the pseudoaneurysm or the age of the lesion. CONCLUSIONS: In patients on anticoagulants and in patients with AV fistulas, the detection of a communicating channel that could be obliterated by direct mechanical compression was discerned as a discriminant factor of success.