Popliteal entrapment syndrome and age.

On the occasion of diagnosing a popliteal entrapment syndrome in a 59-year old man with no cardiovascular risk factors, who developed acute ischemic leg pain during long distance running, we give an overview on this entity with emphasis on patients' age. The different types of the popliteal artery compression syndrome are summarized. The diagnostic and therapeutic approaches are discussed. The most important clinical sign of a popliteal entrapment syndrome is the lack of atherosclerotic risk factors in patients with limited walking distance. Not only in young athletes but also in patients more than 50 years old the popliteal entrapment syndrome has to be taken into account.

[Superficial venous thrombosis. A review]. / Oberflächliche Venenthrombose. Eine Übersicht.

This review summarizes the epidemiology, clinical aspects, diagnosis and new therapeutic options of the superficial venous thrombosis. An important new finding is, that the thrombophlebitis is actually a thrombosis, which occurs in an intra- or epifascial vein. It can be associated with deep venous thrombosis or pulmonary embolism, thus carrying considerable risk. Other underlying diseases such as underlying tumors or infections as well as acquired or inherited disorders of coagulation must be considered. New placebo-controlled studies show a clear benefit for low molecular weight heparin or the pentasaccharide fondaparinux. In addition to the medical treatment, compression is recommended for superficial venous thrombosis in varicose veins, but not in normal veins.

Unusual vascular focal high-grade arterial stenoses in a young woman with systemic lupus erythematosus and secondary antiphospholipid syndrome.

We report the case of a 28-year old woman with an unusual presentation of peripheral arterial occlusive disease clinically characterized by intermittent claudication and bilateral, focal stenoses of the iliac arteries without signs of atherosclerosis in other vascular beds. The successful percutaneous intervention is described in detail and pathogenetic aspects of the disease are discussed.

Varicose veins: a critical review of the definition and the therapeutical options.

This review intends to give an overview of the present therapeutic options for varicose vein disease. The definition of varicose vein disease and its recurrence are made and discussed with new aspects including duplexsonography assessment. All therapeutic approaches have developed and refined their treatment modalities, the open surgical as well as the endovenous techniques. In particular the “new” endovenous techniques are described with regard to safety and outcome, the published literature in this respect is summarized. The studies comparing the different techniques are listed, the prospective long term studies comparing the new techniques with the so called gold standard (open surgery) shall decide on the fate of the different techniques.

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.

Acute deep vein thrombosis: early mobilization does not increase the frequency of pulmonary embolism.

Outpatient treatment for acute symptomatic deep vein thrombosis (DVT) was shown to be safe for most patients. However, little is known whether patients treated on an outpatient basis were ambulating or predominantly resting, a factor which may be decisive for the outcome. In the present study 129 DVT patients were randomized to either strict immobilization for 4 days or to ambulate for > or = 4 hours per day under supervision in order to show, whether the old concept of temporary immobilization is superior to early mobilization or not. The DVT diagnosis was based on duplex sonography; all patients were screened for PE at baseline and at day 4 by pulmonary ventilation-perfusion scanning, and were followed up for a total of 3 months. Clinically, changes in leg circumferences and leg pain were evaluated. The frequency of PE at baseline was 53.0% and 44.9% in the immobile and the mobile groups, respectively. During the 4 days observation period new PEs were found in 10.0% and in 14.4% of the immobilized and the ambulating patients (delta 4.4%; 95% CI -0.5 to 13.8; chi2 = 0.596, p = 0.44). The occurrence of new PE was related to the presence of PE at baseline but not to other potential predictors. The magnitude of a decrease in leg circumferences and leg pain was comparable in both groups. No patient died during the 4 day observation period. The total 3 month mortality rate was 3.9% (5 patients; 2 from the immobile, 3 from the ambulating group). All 5 patient suffered from malignancies. The results of this study show in accordance with the trial hypothesis that, regarding the frequency of PE, immobilization is not superior to early mobilization, suggesting that early mobilization is safe.

The number of circulating CD34+ blood cells predicts the colony-forming capacity of leukapheresis products in children.

In children, only a few guidelines are available for optimizing peripheral blood progenitor cell (PBPC) harvesting. We analyzed by means of flow cytometry and clonogenic assays 60 harvest products obtained from 20 children by standardized leukapheresis after treatment with chemotherapy and CSF. In addition, 27 fresh blood samples obtained prospectively during the mobilization phase were studied. CFU-GM/kg significantly correlated with MNC/kg, CD34+ cells/kg and CD34+33- cells/kg in apheresis products (P < 0.001). In fresh blood samples, CFU-GM/ml significantly correlated with MNC/ml, CD34+ cells/ml and CD34+33- cells/ml (P < 0.001). The numbers of CD34+ cells/ml, CD34+33- cells/ml and MNC/ml in 19 blood samples taken prior to leukapheresis were compared with CFU-GM/kg harvested and thawed after cryopreservation applying multiple regression analysis with stepwise variable selection. The number of circulating CD34+ cells/ml prior to leukapheresis highly correlated with and was predictive for the number of collected CFU-GM/kg (P < 0.001). In addition, a significant correlation (P < 0.05) between the number of progenitor cells/kg reinfused and the time to myeloid and platelet recovery was found in children undergoing high-dose therapy. Our data indicate that a single leukapheresis will be sufficient to obtain a minimum number of 5 x 10(4) CFU-GM/kg if the pre-harvest number of circulating CD34+ cells is > or = 10(5)/ml. Thus, our results will help to optimize PBPC transplantation in children.

Erythrocyte adenosine triphosphate depletion during voluntary hyperventilation.

Chronic hypophosphatemia in humans is associated with a slow depletion of adenosine triphosphate (ATP) and 2,3-diphosphoglycerate (2,3-DPG) in erythrocytes, combined with shape alteration, impaired deformability, and viability of the cells. Likewise, incubation of erythrocytes in alkaline solution is associated with ATP depletion. Since in hyperventilation both hypophosphatemia and alkalosis are present, we have investigated red cell organic phosphates, shape, deformability, and osmotic fragility before, during, and after 20 min of voluntary hyperventilation. On the average, red cell ATP decreased by 42%, the blood pH increased by 0.2 units, and plasma inorganic phosphorus decreased by 46% compared with the initial values. Red cell 2,3-DPG, shape, deformability, and osmotic fragility remained unchanged. After the end of hyperventilation ATP increased rapidly to control values in parallel with the normalization of the blood pH, whereas inorganic plasma phosphorus remained at the low level observed during hyperventilation. It is concluded that the combined effects of hypophosphatemia and alkalosis in acute hyperventilation lead to an isolated fall of red cell ATP, which occurs as rapid as after total inhibition of red cell glycolysis in vitro.

Assessment of collateral perfusion: a pharmacodynamic study with buflomedil hydrochloride.

The aim of the study was to assess the influence of Buflomedil hydrochloride on collateral function. Ten patients with isolated superficial femoral occlusions were investigated twice by duplex sonography with measurement sites at the common femoral artery (CF) and the popliteal artery (PA). After the second scan 200 mg of Buflomedil hydrochloride were infused; the infusion was followed by a third duplex examination. Endpoints assessed included the arterial diameter (D(CF), D(PA)), the systolic peak velocity (Vmax), the mean velocity of the maximum envelope (Vmean m.e.), the intensity weighted time average mean velocity (Vmean i.w.), the maximum reverse flow velocity (Vrev), the end-diastolic velocity (Venddiast), the calculated volume flow (Q), the pulsatility and the resistance indices (PI, RI), and PI and RI based segmental damping factors (DF(PI), DF(RI)). For the CF measurement site the infusion of Buflomedil hydrochloride resulted in a significant reduction in Vrev and PI (p<0.05), whereas trends in the opposite direction (increase) were observed for both measures of Vmean and for Q (0.1

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.

[Unilateral swelling of the leg]. / Die einseitige Beinschwellung.

Unilateral swelling of the leg is a common problem in general practice. The spectrum of underlying diseases is broad and does include venous and lymphatic disorders but also less frequent diseases such as Baker cysts and Sudeck's dystrophia. In the majority of cases a diagnosis can be made based on the patients history, the clinical findings and some specific laboratory and/or instrumental investigations. Selected cases however, require the attention of the vascular specialist.

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.

Performance of coagulation tests in patients on therapeutic doses of dabigatran: a cross-sectional pharmacodynamic study based on peak and trough plasma levels.

BACKGROUND: Knowledge of anticoagulation status during dabigatran therapy may be desirable in certain clinical situations. OBJECTIVE: To determine the coagulation tests that are most useful for assessing dabigatran's anticoagulant effect. METHODS: Peak and trough blood samples from 35 patients taking dabigatran 150 mg twice daily, and one sample each from 30 non-anticoagulated individuals, were collected. Mass spectrometry and various coagulation assays were performed. 'Therapeutic range' was defined as the range of plasma dabigatran concentrations determined by mass spectrometry between the 2.5th and 97.5th percentiles of all values. RESULTS: The therapeutic range was 27-411 ng mL(-1) . The prothrombin time (PT) and activated partial thromboplastin time (APTT), determined with multiple reagents, and activated clotting time (ACT) were insensitive to therapeutic dabigatran: 29%, 18% and 40% of samples had a normal PT, APTT, and ACT, respectively. However, normal PT, ACT and APTT ruled out dabigatran levels above the 75th percentile. The thrombin clotting time (TCT) correlated well and linearly with dabigatran levels below the 50th percentile, but was unmeasurable above it. The dilute thrombin time, ecarin clotting time and ecarin chromogenic assay showed linear correlations with dabigatran levels over a broad range, and identified therapeutic and supratherapeutic levels. CONCLUSIONS: The prothrombin time, APTT and ACT are often normal in spite of therapeutic dabigatran plasma levels. The TCT is useful for detecting minimal dabigatran levels. The dilute thrombin time and chromogenic and clotting ecarin assays accurately identify therapeutic and supratherapeutic dabigatran levels. This trial is registered at www.clinicaltrials.gov (#NCT01588327).

Venous reflux and venous distensibility in varicose and healthy veins.

OBJECTIVES: The aim of this study was to analyse venous diameter changes and venous reflux parameters, assessed during a standardised Valsalva manoeuvre in healthy subjects and in patients with varicose veins. METHODS: Measurements were carried out in 444 vein segments, (96 legs of 48 healthy volunteers, 52 legs of 35 patients with varicose veins). The common femoral vein (CVF), the femoral vein (FV) and the great saphenous vein (GSV) were investigated. The parameters of reflux and the relative venous diameter change (VD diff %) were measured simultaneously during a standardised Valsalva manoeuvre. RESULTS: Venous diameter changes during Valsalva manoeuvre (VD diff) were significantly greater in the GSV and in the deep veins of varicose patients compared to healthy subjects. The median (Interquartile range) of VD max in the CFV was: 13.1 (3.5) mm and 11.2 (3.4) mm (p=0.0002, Mann-Whitney - U test), in the FV 7.8 (2.7) mm and 6.9 (2.0) mm (p=0.01, Mann-Whitney), in the GSV: 7.3 (3.7) mm and 4.2 (1.1) mm (p<0.0001, Mann-Whitney) for the varicose and healthy veins respectively. Good correlation was seen for the retrograde peak reflux velocity (PRV) and VD diff % in varicose veins (r=0.71 (0.57 - 0.81) p<0.0001, Mann-Whitney). CONCLUSION: Relative venous diameter--changes during a standardised Valsalva manoeuvre are significantly larger in the deep and superficial veins of varicose vein patients compared with healthy veins, the increased distensibility correlates with venous reflux parameters in varicose vein patients.

Selective loss of extracellular matrix proteins is linked to biophysical properties of varicose veins assessed by ultrasonography.

BACKGROUND: Dilatation and enhanced distensibility are specific biophysical properties of varicose veins. Both can be assessed by ultrasonography. The aim of this study was to analyse correlations between the vein wall protein content and these two biophysical properties of varicose veins. METHODS: Twenty-seven patients having surgery for varicose veins and six control patients with normal veins undergoing arterial bypass surgery were examined clinically and with ultrasonography the day before surgery. Fifty-two varicose and six control vein rings were harvested and analysed histopathologically and morphometrically; vascular tissue microarrays incorporated 116 vein wall sectors. RESULTS: Elastin loss in the adventitia (P = 0.010) and reduction of type III collagen in the intima and media (P = 0.004) were observed in varicose veins. Elastin loss correlated negatively with vein diameter at rest (P = 0.005), whereas loss of type III collagen in the intima correlated negatively with the increase in vein diameter at the Valsalva manoeuvre (P < 0.001). CONCLUSION: Loss of elastin and type III collagen occurs in varicose veins and can be assessed with ultrasonography in vivo by measuring vein diameter and distensibility.

[Infectious spondylitis]. / Die infektiöse Spondylitis.

Nowadays, early diagnosis of spondylitis is possible. Technetium and gallium scintigrams are positive soon after the onset of the disease, while radiographs remain negative for weeks or even months. Blood and urine cultures and serologic tests may provide indications about the underlying infectious agent; however, needle biopsy establishes a precise bacteriologic diagnosis in up to 65% of the cases. Therefore, needle-biopsy is considered to be the most valuable diagnostic measure in spondylitis. Conservative treatment is indicated in cases of minimal destruction of the vertebral body. Surgery may be considered in cases of massive bone loss and kyphosis, and is strictly indicated in cases with spinal instability, abscess formation, and neurologic or septic complications, and when conservative treatment is ineffective.

Modified in vivo platelet retention test for evaluating primary haemostasis.

We present a modified in vivo platelet retention test for evaluating platelet plug formation in a standardized incision applied to the skin (template bleeding time). In contrast to previously published similar procedures we determined platelet retention at defined time intervals. The investigation of 20 healthy subjects with this method revealed a characteristic biphasic pattern of platelet consumption at the wound surface, which could be correlated with primary and secondary platelet aggregation. In 10 patients with congenital platelet dysfunction and 2 patients with von Willebrand's disease the pattern of platelet retention was affected principally in its early phase, whereas aspirin, when given to 2 healthy subjects, inhibited platelet retention predominantly in its late phase. Our modified platelet retention test provides information about dynamic events associated with platelet plug formation in both normal and disordered primary haemostasis and may also be useful for evaluating in vivo effects of antithrombotic drugs.

[Clinical value of bilateral measuring of blood pressure]. / Klinische Bedeutung der bilateralen Blutdruckmessung.

By describing six patients who present with a multitude of clinical signs we want to demonstrate the importance of bilateral blood pressure readings. In patients with repeated blood pressure differences in the two arms of greater than 20 mmHg [1] further examination by ultrasound and/or angiography is indicated.

[The effect of low fibrinogen concentrations on human blood viscosity]. / Der Einfluss von niedrigen Fibrinogen-konzentrationen auf das Fliessverhalten von menschlichem Blut.

Simultaneous studies of viscosity, red cell aggregation and deformation were carried out on human blood with different fibrinogen concentrations using a Brookfield viscometer fitted with a reflection photometer. Fibrinogen progressively increased rouleaux formation, while decreasing viscosity at low and increasing it at higher concentrations. This antagonism is explained by the specific hemodynamic effects of the rouleaux formed under either condition.

Effect of low fibrinogen concentrations on the rheology of human blood in vitro.

The influence of low concentrations of fibrinogen on the rheology of normal human blood was investigated with an instrument that permitted simultaneous determination of viscosity and the state of red blood cell aggregation and deformation. Fibrinogen, in concentrations of 9-82 mg/100 ml, decreased blood viscosity at all shear rates below the value obtained with red blood cells suspended in serum. At concentrations above 116 mg/100 ml viscosity was increased. Aggregate formation increased progressively as the fibrinogen concentration increased, necessitating higher dispersing shear rates. The deformation and alignment of the red cells, occurring at a shear rate of 230 s-1, was facilitated by low concentrations. The effect of fibrinogen on low-shear viscosity is explained by the formation of different kinds of aggregates. At low concentrations, the aggregates consist of only few cells forming spherelike particles displaying hemodynamic properties better than those of the single discoid cells. At normal or high concentrations big rodlike aggregates occur and increase resistance to flow.