Comparison of saruplase and alteplase in acute myocardial infarction. SESAM Study Group. The Study in Europe with Saruplase and Alteplase in Myocardial Infarction.

Four hundred seventy-three patients with acute myocardial infarction (AMI) were treated with either saruplase (80 mg/hour, n = 236) or alteplase (100 mg every 3 hours, n = 237). Comedication included heparin and acetylsalicylic acid. Angiography was performed at 45 and 60 minutes after the start of thrombolytic therapy. When flow was insufficient, angiography was repeated at 90 minutes. Coronary angioplasty was then performed if Thrombolysis In Myocardial Infarction (TIMI) trial 0 to 1 flow was seen. Control angiography was at 24 to 40 hours. Baseline characteristics were similar. Angiography showed comparable and remarkably high early patency rates (TIMI 2 or 3 flow) in both treatment groups: at 45 minutes, 74.6% versus 68.9% (p = 0.22); and at 60 minutes 79.9% versus 75.3% (p = 0.26). Patency rates at 90 minutes before additional interventions were also comparable (79.9% and 81.4%). Angiographic reocclusion rates were not significantly different: 1.2% versus 2.4% (p = 0.68). After rescue angioplasty, angiographic reocclusion rates of 22.0% and 15.0% were observed. Safety data were similar for both groups. Thus, (1) early patency rates were high for saruplase and alteplase treatment, (2) reocclusion rates for both drugs were remarkably low, and (3) complication rates were similar. Thus, saruplase seems to be as safe and effective as alteplase.

Role of venous duplex imaging of the lower extremities in patients with fever of unknown origin.

BACKGROUND: Although a fever of unknown origin (FUO) is most often due to other causes, the few caused by pulmonary emboli, pelvic thrombophlebitis, or lower extremity venous thrombosis (DVT) present a diagnostic challenge. The purpose of this study was to evaluate the role of venous duplex imaging of the lower extremity in evaluating a large series of patients with FUO. This has not been reported previously in the English-language literature. METHODS: Medical records were analyzed of patients with FUO who were referred to the vascular laboratory for venous duplex imaging of the lower extremities to rule out DVT as a cause of their fever. A FUO was defined as a temperature of greater than 38.3 degrees C on several occasions for at least 3 weeks' duration that defied 1 week of hospital evaluation. DVT was considered as a probable cause of FUO if the following criteria were met: (1) a positive venous duplex image for acute DVT, (2) subsequent fever resolution within 7 days of anticoagulation therapy, and (3) a fever that was resistant to prior treatment. RESULTS: A total of 114 duplex examinations, gathered during a 2-year period, were analyzed. The 89 patients had a mean age of 58 years. Infections were the most common cause of FUO (57 of 89, 64%), and unknown causes constituted 19%. There were seven cases of DVT (8%), five (6%) of whom met the criteria for probable cause of FUO. The overall cost of venous duplex imaging examinations was $51,300 ($450 x 114 tests), with an average cost of $10,260 for each case of DVT detected as probable cause of FUO. CONCLUSIONS: Consistent with the literature, infections remain the most common cause of FUO; however, DVT was found to be a more common cause of FUO in our present series (6%). The cost of venous duplex imaging of the lower extremities in establishing DVT as a probable cause of FUO should be borne in mind when the work-up of these patients is planned.

Brachiocephalic revascularization: a comparison between carotid-subclavian artery bypass and axilloaxillary artery bypass.

Sixty-seven patients who underwent carotid-subclavian bypass (CSBP) (28 CSBPs only and eight with carotid endarterectomy) or axilloaxillary artery bypass (n = 31) with polytetrafluoroethylene grafts were followed up for a mean of 69.2 and 71.9 months, respectively. Indications for surgery in the CSBP group included hemispheric transient ischemic attack (TIA)/cerebrovascular accident in five, nonhemispheric TIA in seven, upper extremity ischemia in 15, and combined TIA and arm ischemia in nine patients. In the axilloaxillary artery group, two patients had hemispheric TIA, five had nonhemispheric TIA, 12 had upper extremity ischemia, and 12 had combined TIA and arm ischemia. Graft patency was determined clinically and confirmed by segmental Doppler pressures, duplex ultrasonography, or angiography. The 30-day mortality rate was approximately 3% in both groups. The 30-day complication rate was 3% for the axilloaxillary artery group and 8% for the CSBP group (not statistically significant). Relief of symptoms was achieved in 100% of patients in both groups; however, 20% of the patients in the axilloaxillary artery group had a recurrence of symptoms, in contrast to 5.6% in the CSBP group. The cumulative 10-year primary and secondary patency rates, calculated by life-table analysis, were 66% and 84.6% for the axilloaxillary artery procedures and 93.8% and 93.8% for the CSBP procedures, respectively (statistically significant). Concomitant carotid endarterectomy with CSBP did not influence graft patency. In conclusion, both bypasses have comparable morbidity and mortality rates; however, the CSBP has a statistically significantly better primary patency rate than the axilloaxillary artery bypass. Therefore CSBP should be the procedure of choice and the axilloaxillary artery bypass should be restricted to high-risk patients.

Elective resection of 332 abdominal aortic aneurysms in a southern West Virginia community during a recent five-year period.

This study analyzed 33 variables that might potentially affect outcome in a series of 332 consecutive elective abdominal aortic aneurysm repairs in a southern West Virginia community. One of the interesting features of this series was that the repairs were done by 22 surgeons with varying degrees of experience. The mortality and complication rates were compared for various potential risk factors by both univariant methods (chi 2, Fisher's exact, and Student t tests) and multivariant methods of analysis. Our early mortality (2.1%) and postoperative complication rates were consistent with those of other series. With multiple linear regression models, five factors were selected as significant independent risk factors associated with an increasing number of postoperative complications: the number of blood transfusions (p less than 0.0001), left renal vein ligation (p less than 0.0001), the presence of greater than 50% renal artery stenosis (p = 0.0012), the lesser experience of the surgeon (p = 0.0203), and the history of prior cardiac catheterization (p = 0.0245). The only factor statistically correlated with mortality rate was an increased number of postoperative complications (p less than 0.0001). Neither postoperative complications nor mortality rate was found to be significant and independently influenced by other demographic, clinical, or operative factors. It is tempting to speculate that surgeons with less experience might be well served to refer patients with significant renal artery stenosis and coronary artery disease. Our mortality and complication rates were not increased by performing preoperative angiography and therefore prudent surgeons may find this helpful in selecting patients for safer repair.

Polytetrafluoroethylene grafts in infrainguinal arterial revascularization. Factors affecting outcome.

One hundred thirty-seven polytetrafluoroethylene infrainguinal bypass grafts were performed over 2 years. The results were analyzed using univariate and multivariate analyses. Our operative mortality was 3.2% and the post-operative amputation rate was 5.8%. Forty-eight reconstructions were done for claudication, with a 5-year secondary patency rate of 64%, no early amputations, and a 2.9% (one limb) late amputation rate. Sixty-six reconstructions were done for rest pain with a 5-year secondary patency rate of 58% and a 3-year limb salvage rate of 77%. The 5-year secondary patency rate for 23 patients with trophic changes was 30%, and the 3-year limb salvage rate was 71%. Multivariate analysis identified the ankle-brachial index as the most important independent factor predicting both primary and secondary graft patency. The cumulative primary and secondary patency rates for patients with an ankle-brachial index of less than 0.5 at 78 months was 37% and 46%, respectively; and 57% and 68%, respectively for patients with an ankle-brachial index of 0.5 or more.

Diagnostic and therapeutic strategies of white clot syndrome.

This study describes our experience with 12 patients with white clot syndrome encountered during a recent 36-month period. The diagnosis was based on the following criteria: (1) development of thrombocytopenia of less than 100,000/mm3 during administration of heparin therapy, (2) normalization of the platelet count after an interruption in heparin therapy, (3) exclusion of other causes of thrombocytopenia, (4) a positive heparin-induced platelet aggregation test, (5) detection of white clots on pathologic examination, and (6) the presence of thrombotic complications. Of 2,500 patients who received heparin therapy, 12 (0.48%) developed white clot syndrome. Various indications, routes of administration, and types of heparin were implicated. The mean platelet nadir was 26,900/mm3, and the mean time to onset of heparin-induced thrombocytopenia was 5 days. Thrombotic complications included arterial occlusions of the legs in 11 patients, deep vein thrombosis of the legs in 9 patients (4 had pulmonary embolism), and combined arterial and venous thrombosis in 8 patients. Treatment strategies included discontinuation of heparin in all patients and intravenous infusion of dextran, followed by arterial thrombectomy in four patients, urokinase therapy in two patients for arterial complications, and insertion of Greenfield filters in six patients. All patients were given warfarin. The mortality rate was 25% and the morbidity rate was 50%. An initial platelet count should be obtained on all patients prior to receiving heparin, followed by repeat platelet counts every 2 to 3 days. Once thrombocytopenia or thrombosis is diagnosed, heparin should be discontinued and other methods of therapy considered.

Safety of arteriography by direct puncture of a vascular prosthesis.

A total of 122 catheterizations were performed in 105 patients with femoral grafts. Ninety-five femoral grafts were punctured. The mean follow-up time was 21 months. Sixty-one patients had follow-up duplex ultrasounds of the graft puncture site at 6 months. The complication rates for patients with direct graft puncture were comparable to those of patients without grafts undergoing femoral catheter arteriography. Twenty-seven cases with femoral grafts had arteriography using the transaxillary technique. The overall complication rate for the 95 cases with graft puncture was 12% (8% were minor complications) in contrast to 30% (22% were major complications) for the 27 cases with the transaxillary approach. The local, nervous system, and major complication rates were all significantly less in patients with graft puncture than in patients with the transaxillary approach. There was no evidence of early or late pseudoaneurysm formation, disruption of the suture line, or late graft infection in patients with graft puncture. Direct graft puncture arteriography is safe and preferable to the transaxillary approach.

Adjunctive intraoperative linear extrusion (Fogarty-Chin) balloon angioplasty.

Eighty-nine patients with 94 stenotic segments (mostly iliac or femoral) underwent balloon angioplasty with the first-generation (no guidewire) linear extrusion (Fogarty-Chin) system, in an adjunctive mode, and the overall long-term patency rate (mean follow-up: 21 months) was 81%. Patients were grouped into those having iliac or superficial femoral artery (SFA) lesions and subdivided according to the length of lesions. The overall primary and late success rates for iliac lesions were 95% and 86%, respectively, and for SFA lesions 91% and 76%, respectively. The primary and late success rates for iliac lesions less than 2 cm were 100% and 96%, respectively, and for iliac lesions 2 cm to less than 5 cm 92% and 80%, respectively. The primary and late success rates for SFA lesions less than 2 cm were 100% and 100%, respectively; for lesions 2 cm to less than 5 cm 100% and 83%, respectively; and for lesions 5 to 10 cm 83% and 67%, respectively. A stratified analysis by vessel and segment length reveals that, in SFA lesions with a segment length greater than 5 cm, there is a significantly lower patency rate (67%) when compared with the combined results of the Fogarty-Chin balloon angioplasty system in iliac and femoral artery lesions less than 5 cm (92%). In comparing the composite results presented in a recent text on endovascular surgery by Moore and Ahn as the base data for the standard coaxial (Gruntzig) balloon system, our results (short and long term) are similar.

Conventional versus thrombolytic therapy in spontaneous (effort) axillary-subclavian vein thrombosis.

Effort axillary-subclavian vein thrombosis in young patients has produced long-term disability because of the failure of the thrombosed vein to recanalize. Ten consecutive patients treated in our institution were analyzed. All patients were diagnosed by venography. Four patients received thrombolytic therapy. Three of these had complete resolution and one had partial resolution of the symptoms and thrombus, that was confirmed by venography and duplex imaging. The remaining six patients were treated with conventional anticoagulant therapy. Three of these patients had no resolution, one had complete resolution of both symptoms and thrombus, and two had only partial resolution of symptoms but no resolution of thrombus. Thrombolytic therapy appears to be superior to anticoagulation in the dissolution of symptoms in effort vein thrombosis and should be considered in its management if the diagnosis is made early.

Cross-filling of circle of Willis and carotid stenosis by angiography, duplex ultrasound, and oculopneumoplethysmography.

PURPOSE: To evaluate the filling of the Circle of Willis on preoperative arteriograms and to correlate this observation with the results of oculopneumoplethysmography (OPG) and severity of carotid stenosis as determined by duplex ultrasonography and angiography. PATIENTS AND METHODS: Ninety-five patients underwent OPG, duplex ultrasonography, and selective carotid and vertebral arteriography. RESULTS: In all, 45 (88%) patients with a positive OPG had interhemispheric cross-filling of the middle cerebral artery and anterior cerebral artery from a contralateral carotid injection in contrast with 10 (23%) patients with a negative OPG (P < 0.001). Of patients with carotid stenosis > or = 80% on duplex ultrasound, 39 (91%) had cross-filling from a contralateral carotid injection in contrast with 16 (31%) patients with < 80% stenosis (P < 0.001). Of patients with carotid stenosis > or = 80% on arteriogram, 37 (90%) had cross-filling from a contralateral carotid injection in contrast with 18 (33%) patients with < 80% stenosis (P < 0.001). CONCLUSION: These data suggest that the Circle of Willis is frequently incompetent as a collateral pathway and that arteriographic cross-filling is not a reliable index of this pathway. Patients with a positive OPG and corresponding carotid stenosis are likely to have a physiologically incompetent collateral pathway. Perhaps these patients should undergo surgery, even if the stenosis is less than 80%.

Four-compartment fasciotomy of the lower extremity without fibulectomy: a new approach.

A technique for a four-compartment decompression of the leg is described in three patients with return to normal of compartment pressures. The technique involves incision of the interosseous membrane, and the posterior intermuscular septa. No fibulectomy was performed.

Management of deep vein thrombosis of the lower extremity in pregnancy: a challenging dilemma.

This study reviews our experience in the management of deep vein thrombosis (DVT) of the lower extremity during pregnancy and analyzes the outcome of various treatment alternatives, including conventional full-dose heparin therapy and Greenfield filter insertion. Twenty-four patients treated over an 8-year period were reviewed. Fifteen patients were treated with conventional full-dose intravenous heparin therapy for 5 to 10 days, followed by subcutaneous low-dose heparin until labor, and continued for 6 weeks postpartum (Group A); Eleven patients had Greenfield filters inserted, followed by the same low-dose subcutaneous heparin regimen (Group B). There were 18 femoral or iliofemoral, 5 femoropopliteal, and 1 popliteal and below-knee DVT. The indications for Greenfield filter insertion included two patients in Group A (one with pulmonary embolism, despite adequate heparin therapy, and one with significant bleeding). Nine other patients had prophylactic indications: two for free-floating iliofemoral DVT, three with iliofemoral DVT (occurring just 1-2 weeks before labor), and four with femoropopliteal DVT. There were three immediate major complications (pulmonary embolism, bleeding, or death) in Group A; two with pulmonary embolism, one of which was fatal, and one with significant bleeding (3 of 15 patients; 20%). No major complications occurred in Group B. On long-term follow-up (mean, 61 months), 4 of 12 patients (33%) in Group A had significant leg swelling, with partial resolution of DVT in 2 patients and venous occlusion in 2 patients by duplex ultrasound. This is in contrast to 3 of 11 patients (27%) in Group B with significant leg swelling. There was no fetal morbidity or mortality in either group. Conventional full-dose heparin therapy for DVT of the lower extremity in pregnancy can carry significant morbidity and mortality. Greenfield filters may be used safely in some of these patients.

Quick and easy management of superior vena caval syndrome.

Superior vena caval syndrome (SVCS) is a life-threatening medical emergency that is usually treated with high-dose irradiation. Previous attempts at surgical intervention have been disappointing. Recently, the authors have successfully treated a case of SVCS with a axillo-axillary and axillary to femoral venous bypass using an externally supported synthetic graft. This is an easy, safe, and rapid alternative for the emergent treatment of superior vena caval syndrome.

Parietal cell vagotomy for bleeding duodenal ulcers.

From January 1978 to December 1985, 22 parietal cell vagotomies for bleeding peptic ulcers were performed at the Charleston Area Medical Center. Twenty of these operations were done for acute bleeding with an overall complication rate of 27 per cent. There was only one operative mortality, and these results coincide with those of the world literature. Follow-up ranges from 1 month to 6 years with an average of 2 and one half years. Seventy-eight per cent of our patients had a good result defined as either Visick class I (ten patients) or Visick class II (four patients). All of the patients, with the exception of the one mortality, had control of the bleeding. Therefore, the authors believe parietal cell vagotomy should be considered in the treatment of acute bleeding peptic ulcer disease.

The potential value of endotoxin-amylase detection in peritoneal lavage fluid.

Widespread acceptance of Limulus Amoebocyte Lysate testing in clinical situations has been elusive. The results obtained in this series of 38 patients seem to support the contention that the amylase-endotoxin complex can be of value in detecting rapidly and with reasonable sensitivity the presence of pancreatic injury and gastrointestinal perforations. A corrected WBC count appears to add diagnostic possibilities to the technique. Despite the promising evidence detailed in this paper, further studies are required to establish the true sensitivity/specificity of the test. Its validity and utility could be assessed rapidly if traumatologists who routinely perform lavage would utilize this method and report their findings.

The value of sequential peritoneal profile in blunt abdominal trauma.

The performance of a laparotomy in hemodynamically stable patients with hemoperitoneum is based on the need to assess and control hemorrhage and to repair injuries assumed to be significant. This premise could be ignored in selected circumstances if injuries requiring intervention can be recognized early and with reasonable certainty. It is believed that a combination of traditional clinical parameters in conjunction with a modified and sequential lavage technique and a standard analysis of the effluent to include endotoxin, amylase, and corrected white blood cell determinations could increase the diagnostic accuracy in blunt abdominal trauma to permit safe observation of selected patients. Using this approach, 32 trauma victims with gross intraperitoneal blood were treated nonoperatively with no complications. In addition, four patients had gastrointestinal-pancreatic injuries detected in less than 12 hours despite negative clinical signs and red cell lavage counts.

Bronchial carcinoid tumor: experience over 20 years.

Nineteen cases of bronchial carcinoid tumor seen over 20 years in a 1,000-bed, tertiary medical center were retrospectively reviewed. They consisted of 0.4 per cent of all patients with lung tumors. Initial complaints were hemoptysis, persistent pulmonary infection, chest pain, and diarrhea. Two of the five patients with atypical carcinoid tumors came to the hospital with diarrhea as a result of their chemically active tumors. However, seven patients (36%) were asymptomatic and were diagnosed after an abnormal chest radiograph was noted incidentally. Of 13 patients receiving bronchoscopic examination, 9 (69%) had visible tumors. Bronchial biopsy was performed in 7 patients and led to a diagnosis in all seven. Significant bleeding was noted in 3 patients as a result of biopsy. Lobectomy was the most common surgical procedure in this series. Follow-up of these patients was from 6 months to 15 years. The general outcome for patients with typical carcinoid was good. However, all patients with atypical carcinoid died as a result of dissemination.

Antiplatelet therapy and carotid plaque hemorrhage and its clinical implications.

UNLABELLED: One hundred and fifty-four carotid endarterectomy plaques were studied to determine the correlation of multiple intraplaque hemorrhages to (1) carotid symptoms, (2) the percentage of carotid stenosis, and (3) the preoperative antiplatelet therapy. The plaques were evaluated histopathologically for the presence of multiple hemorrhages. The data were analyzed using the chi 2 test. Multiple hemorrhages were noted in 60.4% and single or not hemorrhage in 39.6% of patients with hemispheric symptoms. In patients with nonhemispheric symptoms, 9.4% had multiple hemorrhages and 90.6% has single or no hemorrhages; 89.4% plaques with multiple hemorrhages had stenosis greater than 75% in contrast to 37.5% in plaques with single or no hemorrhage; and 62.5% with single or no hemorrhage had stenosis of less than 75% (p less than 0.001). In patients receiving antiplatelet therapy, 80.1% of plaques with multiple hemorrhages were removed, in contrast to 19.7% from patients not receiving antiplatelets (p less than 0.001). IN CONCLUSION: Multiple intraplaque hemorrhages were seen more often in patients with hemispheric symptoms and are associated with more critical carotid stenosis. Preoperative antiplatelet therapy increases the incidence of repeated plaque hemorrhages; therefore, we question the validity of this therapy in certain patients with carotid disease.

Paradoxical embolism: an underestimated entity. A plea for comprehensive work-up.

UNLABELLED: Forty-one cases of arterial embolism were reviewed. The work-up included M + 2D echocardiography in 29 patients (71%), arteriography in 22 (54%), both echocardiography and arteriography in 19 (46%), and abdominal aortic ultrasound in 18 (43%). The sources of emboli were probable cardiac (8 = 20%)--mural cardiac thrombus detected by echocardiogram; possible cardiac (12 = 29%)--arrhythmias or other cardiac pathology detected without mural thrombus; probable arterio-arterial (7 = 17%)--proximal arterial thrombus detected; probable paradoxical embolism (2 = 5%)--fulfills the Johnson criteria with cardiac defect and right-to-left shunt detected by contrast echo in one patient and cardiac catheterization in the other; possible paradoxical embolism (3 = 7%)--meets two of three Johnson criteria without evidence of other source; and unknown source (9 = 22%)--conventional work-up negative or incomplete. Five of nine patients (56%) less than 50 years old had probable or possible paradoxical embolism, while in two patients (22%), the origin was unknown. CONCLUSION: (1) A significant proportion of patients with an arterial embolus are discharged with the source of emboli unknown, (2) paradoxical embolism must be considered and contrast saline or transesophageal echocardiogram should be done in patients under 50 years old.

Ex-vivo removal of mammalian immunoglobulin G: method and immunological alterations.

We have described a clinically feasible method capable of rapidly and repeatedly removing mammalian IgG extracorporeally by adsorption onto heat-killed, formalin-stabilized Staphylococcus aureus Cowan-I. In dogs, 2-13 grams of IgG were removed in 60-70 minutes, lowering the serum concentration of IgG by 30-70 percent. Serum IgG levels returned to pre-run values within 48-72 hours and, in some cases, were higher than pre-run levels at 48-72 hours. Serum biochemical alterations were generally transient and relatively modest. Peripheral lymphocyte counts showed minimal changes but the percentage of erythrocyte rosette forming cells appeared to increase with successive runs. This method is safe and efficient, and can be repetitively performed at short intervals in dogs. This method may prove useful in diseases in which rapid removal of circulating IgG is desired.