Transluminal atherectomy for occlusive peripheral vascular disease.

The failure of balloon angioplasty to provide a durable result has led to the development of other methods of catheter-associated interventional therapy. In this study, 112 patients with superficial femoral artery stenosis or occlusion were treated with percutaneous atherectomy. Patients were considered to have a simple lesion if the occluded or stenotic arterial segment was less than 5 cm, and a complex lesion if the length of the occluded segment was greater than 5 cm. All atherectomies were performed in the superficial femoral and popliteal arteries; urokinase thrombolysis was used in conjunction with atherectomy in 16 patients. Atherectomy was considered successful if there was less than 20% residual stenosis determined by arteriography. Initial atherectomy results (30 day patency) were 100% successful in the group with a simple lesion and 93% successful in the group with a complex lesion. At a mean follow-up period of 12 months (range 5 to 24), there was a continued patency rate of 93% and 86%, respectively, in the simple and complex groups. In the patients who had restenosis, all pathologic specimens obtained during the second procedure demonstrated myointimal hyperplasia and organized thrombus. Eight major complications (7.1%) occurred, including one fatal myocardial infarction. The complication rate was 3.5% in the simple group and 8.3% in the complex group. With the exception of the myocardial infarction, all complications were associated with catheter entry site hematomas. Femoropopliteal atherectomy has a high rate of success and low morbidity and mortality for both simple and complex lesions and is a viable and competitive alternative therapy for patients with severe peripheral vascular disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary angiography in 506 patients with extracranial cerebrovascular disease.

Coronary angiography was performed during the evaluation of a prospective series of 506 patients (mean age, 65 years) presenting with extracranial cerebrovascular disease and previous neurologic symptoms (N = 288) or asymptomatic carotid bruits (N = 218). Severe, surgically correctable coronary artery disease was documented in 37% of patients suspected to have coronary artery disease by conventional clinical criteria, compared with 16% of those who were not. Severe inoperable coronary disease was present in 9.8% and 1.5% of these respective subsets and was especially common (14%) among diabetics. As the result of this investigation, an algorithm for perioperative cardiac screening has been developed in an attempt to reduce the eventual mortality caused by myocardial infarction in patients who require extracranial reconstruction.

Treatment of deep vein thrombosis and pulmonary emboli in patients with primary and metastatic brain tumors. Anticoagulants or inferior vena cava filter?

There is a common belief that administration of anticoagulants to patients with brain tumors is contraindicated. Between 1982 and 1986, 50 patients with deep venous thrombosis and pulmonary emboli and brain tumors were examined and treated. Twenty-four patients received an inferior vena cava Greenfield filter and 25 patients were treated with anticoagulants. One patient was terminal and received no therapy. Patients in each group were similar with regard to age, sex, primary tumor, computed tomographic findings, and ultimate outcome. At the time of diagnosis, all patients had residual tumor and most had significant cerebral edema and midline shift. There were no complications in the group receiving Greenfield filters. One patient had a pulmonary embolus after the filter was placed and later required anticoagulant therapy. In the group receiving anticoagulants, one patient had focal intraventricular bleeding observed incidentally on computed tomographic scan one month after beginning anticoagulant therapy and was totally asymptomatic. One patient had gastrointestinal tract bleeding five days after beginning anticoagulant therapy with heparin sodium, and the therapy was therefore discontinued. No other patient had significant bleeding. In view of these findings, a reevaluation of anticoagulant therapy in patients with central nervous system tumors is warranted.

Prevalence of atherosclerotic renal artery stenosis in patients with atherosclerosis elsewhere.

PURPOSE: To determine the prevalence of atherosclerotic renal artery stenosis in patients who have atherosclerosis elsewhere but lack the usual clinical clues to suggest renal artery stenosis. PATIENTS AND METHODS: The arteriograms and charts of 395 consecutive patients were prospectively reviewed by a member of the Vascular Medicine Department and a member of the Radiology Department. These patients underwent arteriography as part of the routine evaluation for abdominal aortic aneurysm (109 patients), aorto-occlusive disease (21 patients), lower-extremity occlusive disease (189 patients), and suspected renal artery stenosis (76 patients). Patients in the first three groups did not have the usual clues that suggest renal artery stenosis. RESULTS: There was greater than 50% renal artery stenosis in 41 patients (38%) with abdominal aortic aneurysm, seven patients (33%) with aorto-occlusive disease, 74 patients (39%) with lower-extremity occlusive disease, and 53 patients (70%) with suspected renal artery stenosis. The prevalence of renal artery stenosis was similar in diabetic and nondiabetic patients with abdominal aortic aneurysm, aorto-occlusive disease, or suspected renal artery stenosis, but higher in diabetics with lower-extremity occlusive disease (50%) compared to nondiabetics with lower-extremity occlusive disease (33%) (p = 0.022). High-grade bilateral disease was present in approximately 13% of patients with abdominal aortic aneurysm or lower-extremity occlusive disease, and totally occluded renal arteries occurred in 5% of the patients in these groups. There was an association between increasing degree of renal artery stenosis and the presence of hypertension and worsening of renal function. CONCLUSION: Patients with atherosclerosis elsewhere, especially abdominal aortic aneurysm, aorto-occlusive disease, or lower-extremity occlusive disease, have a high prevalence of significant renal artery stenosis even in the absence of the usual clues to suspect renal artery stenosis. Diabetic patients have a similar prevalence as nondiabetic patients. This information may have important therapeutic implications in patients being considered for vascular surgery.

Safety and efficacy of thrombolytic therapy for superior vena cava syndrome.

The experience at the Cleveland Clinic from 1982 to 1990 using thrombolytic therapy for superior vena cava (SVC) syndrome was retrospectively reviewed. Sixteen patients, 11 of whom had indwelling central venous catheters, were treated with either urokinase (n = 11) or streptokinase (n = 5). Either urokinase (4,400 U/kg bolus followed by 4,400 U/kg/h) or streptokinase (250,000 U bolus followed by 100,000 U/h) was used, and venograms were performed before and after. Overall, 56 percent of patients had complete clot lysis and relief of symptoms. Thrombolytic therapy was effective in eight (73 percent) of 11 patients receiving urokinase and one (20 percent) of five patients receiving streptokinase. Of those with a central venous catheter, eight (73 percent) of 11 patients were successfully lysed, whereas only one (20 percent) of five patients was successfully lysed if no catheter was present. If thrombolytic therapy was performed less than or equal to five days of symptom onset, seven (88 percent) of eight patients were successful, if thrombolytic therapy was performed greater than five days after symptom onset, two (25 percent) of eight patients were successful. Symptoms were relieved and the catheter was preserved in patients in whom thrombolytic therapy was effective. Factors predicting success were as follows: (1) the use of urokinase compared with streptokinase; (2) the presence of a central venous catheter; and (3) a duration of symptoms less than or equal to five days.

Incidental asymptomatic carotid bruits in patients scheduled for peripheral vascular reconstruction: results of cerebral and coronary angiography.

From 1978 to 1982 routine preoperative coronary angiography was performed in a series of 1000 patients under consideration for elective peripheral vascular reconstruction, including 295 who were selected primarily because of recognized extracranial cerebrovascular disease. Incidental asymptomatic carotid bruits were discovered in 144 (20%) of the remaining 705 patients who primarily were scheduled for such procedures as aortic replacement, lower extremity revascularization, or visceral artery bypass, and 139 of these 144 patients underwent cerebral angiography as well as cardiac catheterization. Carotid stenosis exceeding 50% of lumen diameter was documented by biplanar angiography in 39 (58%) of 67 patients with unilateral bruits and in 54 (75%) of 72 patients with bilateral bruits (p = 0.0471), and greater than 75% stenosis was present in 42% and 46% of these subsets, respectively. Cardiac catheterization revealed severe, surgically correctable coronary artery disease (CAD) in 29% of patients with incidental carotid bruits and in 24% of those without bruits, as well as in 32% of patients who had documented carotid stenosis and in 22% of those who did not. Although these differences were not statistically valid, the incidence of severe, correctable CAD was significantly higher among patients suspected to have CAD by standard clinical criteria (33% to 38%) than among those who were not (13%), irrespective of whether carotid bruits were present (p = 0.0021) or absent (p = 3.48 X 10(-9). Prophylactic carotid endarterectomy was performed in 54 patients (bilateral in nine), with one death (1.6%) and one postoperative stroke. In addition, 153 patients underwent elective myocardial revascularization in an attempt to reduce subsequent surgical risk and enhance late survival, with an early mortality rate of 5.2%. Only three strokes (0.4%) occurred after a total of 714 other peripheral vascular procedures in this series, and the overall operative mortality rate was 2.7%. While this study does not resolve the controversy concerning the management of incidental asymptomatic carotid bruits in patients scheduled for other operations, it provides new perspective regarding synchronous carotid and coronary disease and confirms the low risk for subsequent stroke and death after appropriate carotid and coronary reconstruction.

New techniques for percutaneous renal revascularization: atherectomy and stenting.

All current techniques for PTRA carry the risk of re-stenosis due to intimal hyperplasia and associated complications. More data are now available to better determine the best candidates for PTRA or surgical revascularization. Great progress has been made with the introduction of renal artery stenting. I believe that this technique, when adequately sized and positioned, will give the best long-term results. Further randomized trials are needed to prove that this technique is superior to PTRA.

Preoperative evaluation and management of coronary and carotid artery occlusive disease in patients with abdominal aortic aneurysms.

Aortic aneurysms rarely exist without systemic manifestations of atherosclerosis beyond the confines of the aneurysm. Preoperative evaluation of coronary and carotid disease is critical in the management of patients with abdominal aortic aneurysms in the perioperative period as well as in the long term.

Fibrinogen A alpha and gamma-chain dimers as potential differential indicators of atherosclerotic and thrombotic vascular disease.

Cross-linked fibrin(ogen) dimers are known to be elevated in the plasma of subjects with occlusive vascular disease, and are thought to be fibrin dimers. Immunoelectrophoretic analyses of the dimers, however, indicate that (1) they are predominantly fibrinogen rather than fibrin dimers, and (2) they contain cross-linked A alpha-chains (A alpha-dyads) instead of the gamma-chain dyads that are rapidly formed by factor XIII during blood coagulation. Furthermore, the mobilities of the A alpha-dyads differ from the cross-linked alpha-chain products that accompany the gamma-chain cross-linking by factor XIII. Instead, the mobilities coincide with the distinct A alpha-dyads that are produced by tissue transglutaminase, an intracellular enzyme not normally present in plasma. The intimal fibrinogen deposits in atherosclerotic aortas also possess fibrinopeptide A and cross-linked A alpha-chains. Thus, both the plasma fibrinogen dimers and the intimal fibrinogen deposits appear to derive from the action of released tissue transglutaminase more so than factor XIII. It is proposed that, in the absence of other indications of cytolytic processes, the levels of A alpha-dyads in plasma reflect ongoing cellular injury accompanying atherogenesis. The extent to which gamma-dyads accompany the A alpha-dyads may signal progression of the disease to advanced stages in which ulcerations and occlusive lesions trigger thrombotic complications.

Electrophoretic characterizations of cross-linked fibrinogen derivatives in blood and vascular tissue by zonal immobilization on glyoxyl agarose.

Direct immunoprobing of electrophoregrams of plasma and intimal protein on glyoxyl agarose and composite-gels with polyacrylamide have uncovered novel modes of cross-linking of fibrinogen that differ from those previously characterized. These modes of cross-linking involve the A alpha-chains of fibrinogen and hybrid cross-linking of alpha- and gamma-chains.

Thrombolytic therapy for renal artery occlusions: a preliminary report.

Percutaneous transluminal angioplasty and renal artery revascularization have been successful in controlling blood pressure and preserving renal function in patients with atherosclerotic renal artery stenosis. In addition, thrombolysis appears promising for treatment of patients with total occlusion of renal artery bypass grafts. More experience will be necessary to define its role in native renal artery occlusions. The authors describe successful thrombolysis in two of three patients given thrombolytic therapy for total occlusion of renal arteries.

Thrombolytic therapy. A review (Part 1 of 2).

Despite the discovery of thrombolytic agents more than 50 years ago, only recently has major interest become evident in their use to treat myocardial infarction, venous thromboembolism, and peripheral arterial disease. Use of thrombolytic drugs may result in myocardial and limb salvage as well as improved survival rates and quality of life for patients affected by potentially devastating vascular disease. We review historical highlights, outstanding studies, and important aspects of thrombolytic therapy, emphasizing its use in peripheral vascular disease.

Evaluation of the patient with leg edema.

Leg edema is a common and challenging problem. The possible causes are numerous and are not limited to the vascular system. Bilateral swelling is usually a manifestation of systemic disorder, whereas unilateral swelling has many possible causes, the most common of which is chronic venous insufficiency. By means of the basic history and physical examination, a differential diagnosis can usually be established without extensive use of expensive diagnostic testing.

Deep venous thrombosis and pulmonary embolism. The importance of heightened awareness.

Left untreated, deep venous thrombosis and pulmonary embolism have a high rate of mortality and long-term morbidity. Physicians therefore must maintain a high index of suspicion for these conditions. Accurate diagnosis is facilitated by knowing the most common sites of thrombus formation, the likelihood of propagation, which patients are at greatest risk, signs and symptoms, and which tests to order. Prompt administration of anticoagulants and, in some cases, thrombolytic agents can minimize the consequences of these diseases. Interruption of the inferior vena cava, thrombectomy, and thromboembolectomy are other treatment options.

Fibrinolytic therapy for deep vein thrombosis and pulmonary embolism.

The troublesome sequelae of pulmonary embolism (PE) and deep vein thrombosis (DVT) justify an aggressive therapeutic approach. Results of anticoagulation in patients with DVT have shown that a significant percentage of patients have no clot resolution and may progress to develop the postphlebitic syndrome. Lytic therapy has been more effective, with patients showing improvement within 24 h of treatment. This approach has also been found to compare favorably with anticoagulation in the treatment of PE. Preliminary research also suggests a potential role for recombinant human tissue-type plasminogen activator to resolve PE.