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.

Wall shear rate in supra-aortic vessels: a factor for different atherosclerotic pattern?

BACKGROUND: Atherosclerotic lesions of the upper extremity arise three to five times more often at the origin of the left subclavian artery than on the right side. The aim of this study was to investigate, whether the hemodynamic forces (peak wall shear rate) in the large supra-aortic branches measured by MRI differ in healthy subjects. PATIENTS AND METHODS: Peak wall shear rate (WSR) and blood flow was assessed in the left carotid, left subclavian and innominate artery in ten healthy volunteers (5 females, mean age of 35.2 +/- 9 years) using high resolution (pixel size 0.6 mm 2) magnetic resonance imaging (MRI) flow velocity measurements. RESULTS: There is no difference between the maximum WSR of the three large supra-aortic vessels. Only within the proximal (327 +/- 132s-1) and distal wall (458 +/- 154s-1) of the innominate artery a significant difference (p = 0.011) of the WSR was found. CONCLUSION: The results from this study indicate that WSR is not different in the supra-aortic vessels. Therefore the atherosclerotic pattern in the subclavian and innominate arteries may not be explained by differences in these hemodynamic forces.

Fluorescence microlymphography: diagnostic potential in lymphedema and basis for the measurement of lymphatic pressure and flow velocity.

Fluorescence microlymphography (FML) is an almost atraumatic technique used to visualize the superficial skin network of initial lymphatics through the intact skin of man. Visualization was performed with an incident light fluorescence microscope following subepidermal injection of minute amounts of FITC-dextran 150,000 using microneedles. Emanating from the bright dye depot, the surrounding network of microvessels is filled, documentation performed by photography or video film. In congenital Milroy lymphedema, a lack of microlymphatics (aplasia) is typical while in other primary lymphedemas and in secondary lymphedema after mastectomy or irradiation of proximal lymph nodes, the network remains intact but the depicted area is enlarged. Lymphatic microangiopathy characterized by obliterations of capillary meshes or mesh segments develops in phleboedema with trophic skin changes, progressive systemic sclerosis and Fabry's disease. In lipedema, lymphatic microaneurysms are stained. Microlymphatic pressure may also be measured using FML. For this purpose, glass micropipettes are inserted into the capillaries by means of a micromanipulator and pressure is determined by the servo-nulling technique. Normal subjects produced significantly lower pressure (7.9 +/- 3.4 mmHg) compared to patients with primary lymphedema (15.0 +/- 5.1 mmHg, p<0.001). This characteristic lymphatic hypertension may be improved by complex physiotherapy or local application of prostaglandins. Additionally, a modification of the FML procedure can be used to measure lymphatic capillary flow velocity in controls and patients. FML is suited to confirm the clinical diagnosis of lymphedema, contributes to distinguish among various forms of edema, and is useful in clinical research. In addition, FML has also become a tool for experimental animal studies including the depiction of gastric microlymphatics, the measurement of flow velocity in the naked mouse tail, and in evaluation of lymphangiogenesis in a model of Milroy disease.

Periodic whole body acceleration: a novel therapy for cardiovascular disease.

BACKGROUND: Periodic whole body acceleration in the spinal axis (pGz) applied by a motion platform is a novel treatment modality that induced endothelial nitric oxide release into the circulation of animals, healthy subjects and patients with inflammatory diseases during single treatment sessions in previous studies. We hypothesized that patients with advanced arteriosclerotic diseases who are not candidates for a surgical intervention would clinically benefit from repeated pGz treatments over several weeks through improvement of endothelial function. PATIENTS AND METHODS: 11 patients, 5 men (37 to 71 y) with stable ischemic heart disease, LVEF < 35%, NYHA stage > II, and 6 patients (51 to 83 y, 1 woman) with intermittent leg claudication, Fontaine stage II, were enrolled after optimization of pharmacological therapy. PGz was applied for 40 min, 5 days/week during 5 weeks. Quality of life (SF-36 questionnaire), exercise performance, and endothelial function were assessed at baseline, during the treatment period, and 4 weeks after discontinuation of pGz. RESULTS: PGz was well tolerated. In heart failure paitents, pGz therapy improved quality of life, increased 6 min walking distance by a mean +/- SE of 105 +/- 24 m, and improved postischemic skin hyperemia (p < .05 in all instances). In 4 of 6 patients with intermittent claudication, quality of life, treadmill walking distance and post-ischemic skin hyperemia improved with pGz therapy (p < .05). Four weeks after discontinuation of pGz, most therapeutic effects had vanished in both patient groups. CONCLUSIONS: In patients with severe heart failure and with leg claudication who remain symptomatic despite maximal medical therapy and who were not candidates for surgery, periodic acceleration applied over several weeks improved quality of life and exercise capacity. The clinical benefits appear to be mediated through improved endothelial function.

Lymphatic clearance of the human skin in patients with acute deep vein thrombosis using a novel fluorescent technique.

The purpose of this study was to investigate lymphatic clearance of the human skin in patients with acute deep thrombosis of the femoral vein. In 13 patients with deep vein thrombosis and no other cause for swelling of the limbs, lymphatic clearance of the skin at the foot was measured. Ten microliters of fluorescein isothiocyanatedextran 150,000 were injected intradermally and the fluorescent light intensity of the deposit measured 10 min and 24 hours after injection by window densitometry. In addition, intralymphatic pressure was measured by the servo-nulling system. The results were compared with a sex- and age-matched control group. Fluorescent light intensity decreased by 23.8 +/- 12.3 arbitrary units or by a factor of 1.8 +/- 0.5 in patients with DVT after 24 hours, which was significantly less than in healthy controls (33.7 +/- 8.9 arbitrary units or by factor 5.0 +/- 4.1, p < 0.013). Intralymphatic pressure was not different between the two groups. These results indicate that lymphatic clearance is significantly reduced in the acute phase of deep venous thrombosis.

Acroparesthesia and acral arterial occlusions as first manifestations of essential thrombocythemia.

Thrombocytosis is either caused by a reactive process (secondary thrombocytosis) or by a clonal bone marrow disorder The latter category includes essential thrombocythemia with bleedings and thrombotic complications as major causes of illness and death in this patients. We describe a 43-year-old man with a 6 months history of acroparesthesia in his toes. Half a year after onset of these symptoms, he noticed a bluish discoloration of digit V of his left foot. On first presentation physical examination revealed a bluish discoloration of all toes and a cold and blue digit V of the left foot. Peripheral pulses were all palpable, normal ankle systolic pressure measurements and normal pulse volume recordings except for digit V of the left foot were found. Laboratory tests revealed thrombocytosis of 800000/microliter. On treatment with acetylsalicylacid, prostanoids intravenously and low molecular weight heparin, the patient became asymptomatic and pulse volume recording of digit V was normalized. After exclusion of cardial or vascular sources of embolism by utrasonography bone marrow aspirate and biopsy supported the diagnosis of essential thrombocythemia.

An unusual presentation of giant cell arteritis.

A 77-year-old-man with giant cell arteritis who developed bitemporal scalp ulcerations is described. Since 1946 when Cooke et al. reported the first case of scalp necrosis there were approximately 55 cases published. Scalp ulceration is a rare complication of giant cell arteritis and occurs mainly in elderly persons, particularly women. About half of all patients were presented to dermatologists. Most of the patients (70%) had other serious complications of giant cell arteritis: blindness, gangrene of the tongue and nasal septum necrosis. Seventy percent of the cases were confirmed by a temporal artery biopsy. The necrosis were of varying extent and uni- or bilateral. Although, in most cases necrosis has been located bilaterally as in the presented case. Scalp healing was complete nearly in all patients by conservative treatment within a year. Scalp ulceration is a potentially reversible complication of giant cell arteritis which indicates extensive vessel involvement and adequate coricosteroid therapy is required and essential.

High wall shear stress measured by magnetic resonance is a predictor of restenosis in the femoral-artery after balloon angioplasty.

AIM: Wall shear stress (WSS) has been implied in the pathogenesis of restenosis after percutaneous transluminal angioplasty (PTA). Aims of the present study were to calculate WSS in the superficial femoral artery (SFA) from magnetic resonance imaging (MRI) and from duplex sonography in healthy controls and in patients after PTA of the SFA to evaluate the predictive value of WSS for restenosis. METHODS: WSS was assessed by calculating the slope of velocity profiles at the vessel wall from data obtained with velocity encoded cine MR and with duplex using the formula: Shear stress=4xblood viscosityxpeak blood velocity/internal diameter. Seventeen patients were studied 1 day after successful PTA of the SFA. Restenosis was determined by duplex ultrasound at the 6-months follow-up visit. RESULTS: In healthy controls WSS values calculated from MRI and from duplex were similar (1.86+/-0.35 N/m2 vs 1.88+/-0.34 N/m2, n.s.). In patients the values obtained with duplex were higher than those obtained with MRI (4.1+/-2.3 N/m2 vs 2.4+/-1.2 N/m2, p=0.002). With both methods post-interventional WSS was higher in patients developing restenosis (duplex 5.4+/-2.2 N/m2, MRI 3.1+/-0.9 N/m2) than in those without restenosis (duplex 2.7+/-1.4 N/m2, MRI 1.5+/-0.7 N/m2) and was revealed to be an independent predictor of restenosis (p=0.03). CONCLUSIONS: This is the first study demonstrating that increased post-interventional WSS in the SFA is predictive for restenosis. WSS values obtained with MRI and duplex were different in patients, however with both methods higher WSS was associated with restenosis.

Microlymphatic aneurysms in patients with lipedema.

"Lipedema," a special form of obesity syndrome, represents swelling of the legs due to an increase of subcutaneous adipose tissue. In 12 patients with lipedema of the legs and in 12 healthy subjects (controls), fluorescence microlymphography was performed to visualize the lymphatic capillary network at the dorsum of the foot, at the medial ankle, and at the thigh. Microaneurysm of a lymphatic capillary was defined as a segment exceeding at least twice the minimal individual diameter of the lymphatic vessel. In patients with lipedema, the propagation of the fluorescent dye into the superficial lymphatic network of the skin was not different from the control group (p > 0.05). In all 8 patients with lipedema of the thigh, microaneurysms were found at this site (7.9 +/- 4.7 aneurysms per depicted network) and in 10 of the 11 patients with excessive fat involvement of the lower leg, multiple microlymphatic aneurysms were found at the ankle region. Two obese patients showed lymphatic microaneurysms in the unaffected thigh and in only 4 patients were microaneurysms found at the foot. None of the healthy controls exhibited microlymphatic aneurysms at the foot and ankle, but in one control subject a single microaneurysm was detected in the thigh. Multiple microlymphatic aneurysms of lymphatic capillaries are a consistent finding in the affected skin regions of patients with lipedema. Its significance remains to be elucidated although its occurrence appears to be unique to these patients.

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.

[Electric blue finger nail]. / Blauer Strom unter dem Fingernagel.

Glomus tumors are benign tumors and are most often localized acral. They usually are diagnosed non-invasively by patient's history, clinical examination, duplex ultrasound and MRI-angiography. Need for intervention depends on the symptoms.

Results of endovenous ClosureFast treatment for varicose veins in an outpatient setting.

OBJECTIVE: Endovenous methods are increasingly used to treat varicose veins. We evaluated the outcome of patients treated with the new radiofrequency ablation (RFA)-ClosureFast catheter in an outpatient setting. METHOD: Retrospective analysis of postinterventional duplex ultrasound (DUS), complication rate and quality of life of patients treated for incompetent saphenous veins. RESULTS: Between 2007 and 2009, 155 patients had been treated with ClosureFast. DUS was available from 73 (47%) patients (102 great [GSV] and 16 small [SSV] saphenous veins). After a mean follow-up of 12.2 months (range 1-29 months), DUS showed six (5.9%) open GSV and an occlusion of all treated SSV. One pulmonary embolism had occurred. Mean patient's satisfaction was 8.7 (10 = very satisfied), pain after one week 2.0 (no pain = 0, maximal = 10) and absence of work was 0.9 day (range 0-14 days). CONCLUSION: RFA for incompetent saphenous veins can safely be performed in an outpatient setting with a low complication rate, minimal pain and fast recovery.

Influence of plaque volume on hemodynamic response and stress hormone release in patients undergoing carotid artery stenting.

AIM: Carotid artery stenting (CAS) may cause bradycardia and hypotension due to barostimulation. The impact of periprocedural hypotension on CAS outcome remains controversial. The role of carotid plaque volume and catecholamine hormone release during CAS on hemodynamic changes has not been investigated so far. The aim of this prospective study was to evaluate if carotid artery plaque characteristics are predictive for stress hormone release or for postprocedural hemodynamic instability. METHODS: In 26 patients undergoing CAS, carotid plaque volume and morphology were assessed by two- and three-dimensional (3D)-Duplex sonography prior to the procedure. Arterial plasma adrenaline, noradrenaline and renin concentrations were measured at the time of sheath insertion and 5 minutes after stent placement. ECG, heart rate, and invasive blood pressure were monitored throughout the procedure. RESULTS: CAS caused no significant changes in hormone release, but increasing plaque volume was related to the degree of bradycardia following stent deployment (r=0.57; P=0.01). Plaque size was not associated with postprocedural hypotension. Plaque echogenicity (echolucent, heterogeneous or echogenic) did not correlate with changes in systolic blood pressure, heart rate or catecholamine hormone release. CONCLUSION: CAS caused bradycardia in relation to plaque size, but did not cause catecholamine release which may indicate that the endovascular procedure is not associated with a relevant stress reaction.

Successful reduction of clinical relevant neovascularization with a modified crossectomy combined with a barrier technique after 10-year follow-up.

OBJECTIVE: The aim of this retrospective study was to assess the long-term results of stripping the insufficient great saphenous vein (GSV) with stump coagulation, closure of the cribriform fascia and some additional measures, which will be described in detail. METHODS: Patients treated from 1998 to 1999 for varicose veins had been invited in 2009 for follow-up colour-coded duplex sonography and had been asked to answer a quality-of-life questionnaire. In 2009, the examinations for the study were conducted at a clinic of angiology by an independent and experienced sonographer. RESULTS: From a total of 165 patients, 91 (136 limbs) had been willing to participate in the study. Duplex ultrasound after a mean follow-up of 10.7 years revealed only clinically non-relevant (∅ < 0.3 cm) neovascularizations in 1.5% of all treated legs. No clinical relevant varicosities from the groin had developed. CONCLUSION: The crossectomy combined with stump coagulation and suture of the fossa ovalis, completed with some additional measures, is a successful method to reduce neovascularization and recurrent varicosities, even for redo-crossectomies, without increasing the risk of perioperative complications.

[White small finger in a 45 year old teacher]. / 45-jähriger Lehrer mit weissem Kleinfinger rechts.

We report the case of a 45 year old teacher with a digital ischemia of the small finger of the right hand. Non invasive diagnostics showed a hypothenar hammer syndrome caused by repetitive trauma due to mechanical working, use of a classical espresso machine and playing drums. Diagnostics, etiology and therapeutic options are discussed.

Microvascular regeneration in meshed skin transplants after severe burns.

Function of the skin lymphatics as well as blood perfusion of a meshed transplant is crucial for the healing. The lymphatic regeneration and arterial perfusion of skin transplants after severe burns of the extremities had been studied in eight patients by microlymphography, laser doppler perfusion imaging and transcutaneous oxygen pressure measurements 1, 6 and 18 months after transplantation. One month after transplantation, only fragmented as well as many giant lymphatic skin vessels were present in the transplant. After 6 months a normal lymphatic network had developed in all grafts. The extension of the dye in the lymphatics decreased from 4.5 (0-16) at 1 month to 3.0 (1-6) mm after 18 months, indicating improved lymph drainage capacity. The permeability of the lymphatics in the graft was normal. After 1 month, median laser flux in the transplant was 155.6% (105-246%) of the normal skin but it normalised within 18 months. By contrast, transcutaneous oxygen measurement (TcPO(2)) increased from 44 (21-47) to 55 (50-76) mmHg. In meshed transplants used to cover severely burned skin morphological and functional normal lymphatics develop within 6 months and the initially increased laser flux due to inflammatory reaction normalises. Our results provide important insights into the healing process of skin transplants after burn.

Quality of life survey after endovascular abdominal aortic aneurysm repair in octogenarians.

AIM: The aim of this study was to assess health-related quality of life (HRQOL) after endovascular abdominal aortic aneurysm (AAA) repair in octogenarians compared to younger patients. In addition, a possible association between HRQOL, duration of hospitalisation and preoperative serum C-reactive protein (CRP) was studied. METHODS: 270 consecutive patients (249 men, mean age 73 years, range 52-89 years) with elective endovascular repair of AAA had been retrospectively evaluated. The Nottingham Health Profile (NHP) score was used to assess health related quality of life in 20 patients 80 years or older and in 25 younger patients. RESULTS: The only difference in the NHP score between the two groups was found in physical abilities, where octogenarians had a significant lower score (79.9%, range 32.8-100%) than the younger group (92.2%, range 36.8-100%, P=0.0003). The mean AAA diameter of the octogenarians was 6.4 cm (range 4.1-13.0 cm) and was significantly larger than in non-octogenarians (5.8 cm, range 3.6-12.5 cm, P=0.017). Duration of hospitalisation, CRP-level and prevalence of CAD and PAD were not different in the two groups. Higher preoperative CRP was associated with longer hospital stay. CONCLUSION: Perceived HRQOL in patients undergoing endovascular repair of AAA is equally good in octogenarians and non-octogenarians, however only the score for physical ability is lower in the older group.