Semiquantitative assessment of lower limb atherosclerosis from routine angiographic images.

In the present report a score system is introduced with the aim of analysing routine angiographic images. The system consists of a vectorial score, which codes the pattern of occlusions, stenoses and plaques, and of an additive score describing the severity of the lesions visualised. The technique is suitable for computerised data analysis.

Results of low speed rotational angioplasty for chronic peripheral occlusions.

After experimental investigation using postmortem human arteries, 19 patients with chronic peripheral artery occlusions were treated with a new angioplasty technique between December 1986 and October 1987. In 17 patients the superficial femoral artery and in 2 patients the popliteal artery were completely occluded. The length of the occlusions ranged between 5 and 25 cm (mean 11). The duration--estimated according to patients' history--was 5 to 48 months (mean 17). In 5 patients, durations of up to 30 months had been documented by angiography. A flexible, blunt, motor-driven rotating catheter was introduced through an 8 or 9Fr sheath and rotational angioplasty was performed at low speeds (up to 200 rpm). In 11 of 14 patients in whom this new technique was used as the primary intervention, the occlusions could be successfully reopened. In 2 patients after failure of conventional techniques the rotating catheter could not bypass the preexisting dissections in the same intervention. In 2 of 3 further patients after failure of conventional techniques the occlusions could be successfully reopened in a second intervention after several weeks. In none of the 19 patients did a perforation occur. It is concluded that with the new technique chronic peripheral artery occlusions can be reopened with a high success rate and without the danger of arterial wall perforation. The method can also be used in patients in whom conventional techniques have failed.

Hemodynamic assessment of the iliac disease by proximal thigh pressure and Doppler femoral flow velocity.

In 22 normal and 51 limbs with arterial occlusive disease, upper thigh blood pressure at rest and after the knee exercise, Doppler flow velocity tracing at the common femoral artery, and the mean femoral velocity tracing during the postischemic reactive hyperemia were investigated. These results were compared with angiographic findings, and the diagnostic value for assessing the iliac disease was discussed. Measurement of the upper thigh pressure after the knee exercise enables prediction of the significant stenosis of the iliac artery. The pressure index of 0.55 or less after exercise indicates a significant disease in the iliac artery, which should be corrected prior to distal vessel reconstruction or percutaneous vascular recanalization.

Historical aspects on the development of angiology in Germany.

Clinical angiology is mainly concerned with vessels and disorders of circulation which can be detected and appraised with clinical methods. The arteries and veins of the limbs as well as the major extracranial arteries supplying the brain are primarily involved. The consequences of a peripheral arterial disease were initially recognized as being due to disorders of blood flow only in their most severe forms. A certain correlation of organic arterial alterations with the clinical finding was first made possible by angiography. Initially, both surgeons and internists directed their attention to this new field. However, since only surgery could offer therapeutic measures promising success, angiology could not become established in internal medicine. Deviating from this general development, Ratschow in Germany and in German-speaking countries and regions was able to create the precondition for an internal medical angiology and to attract the clinical and scientific interest of young internists in this field. The development of modern angiology, which began in the 1950s with the introduction of reconstructive arterial operations hence encountered surgical and internal medical activities in German-speaking countries. In parallel with the improvement in the methods of surgery, the internist angiologists developed thrombolysis and catheter recanalization (angioplasty) into efficient methods of treatment. In addition, the purely conservative techniques of therapy (training, vasoactive substances, rheological methods, medical prophylaxis) as well as noninvasive diagnostics were improved. The ideal concept which is aspired to at present and which has already been put into practice in many places consists in constructive collaboration of internal medical angiology and reconstructive vascular surgery, if possible with the assistance of vessel-oriented radiology.

Clinical significance of Doppler velocity and blood pressure measurements in peripheral arterial occlusive disease.

In 20 normals and 50 limbs with arterial occlusive disease, Doppler flow velocity and blood pressure in different levels of the leg were determined at rest and during reactive hyperemia. While blood pressure measurement at the ankle and flow velocity analysis at the posterior tibial artery were of use in the diagnosis of arterial occlusion, recording the mean femoral flow velocity during reactive hyperemia showed less diagnostic value. Ankle blood pressure was determined after two different exercises--knee exercise and ankle exercise. A greater decrease of blood pressure was observed after ankle exercise than after knee exercise in limbs with isolated occlusion of the femoral artery, and a less decrease in limbs with isolated occlusion of the iliac artery. These findings indicate that comparison of ankle blood pressure after two exercises is useful as a screening test to detect the combined ilio-femoral diseases.

[Long-term arterial blockade and retrograde venous perfusion in peripheral arterial occlusive diseases]. / Langdauernde arterielle Sperre und retrograde Venenperfusion bei peripheren arteriellen Durchblutungsstörungen.

The method of longterm artificial arterial blockade in patients with peripheral arterial occlusive disease (PAOD) opens new therapeutic possibilities. However, it is yet not clear if and how the suspected dilation of collateral arteries can be therapeutically used. The retrograde venous perfusion permits the transport of active substances in high concentrations into ischemic areas. The resulting temporary local damping or even blockade of sympathetic innervation can under certain conditions achieve therapeutic effects. A longterm arterial blockade can be performed even in case of trophic lesions. This permits treatment in stage IV of PAOD. It has been proved that antibiotics reach a lesion by retrograde venous perfusion faster and better than by systemic application, especially in badly compensated cases. However, sufficient experience on the therapeutic effect and possible side effects in stage IV is still lacking.

[Gingko biloba extract EGb 761 and pentoxifylline in intermittent claudication. Secondary analysis of the clinical effectiveness]. / Gingko-biloba-Extrakt EGb 761 und Pentoxifyllin bei Claudicatio intermittens. Sekundäranalyse zur klinischen Wirksamkeit.

Clinical trials on the efficacy of EGb 761 and pentoxifylline are summarized in the context of their methods and results and compared with each other. All placebo-controlled, randomized and double-blind studies with the major target objective of "pain-free walking distance" were selected. The pentoxifylline studies were adopted from a survey of the existing literature in the English language, which has been brought up to date via DIMDI research. The studies on both active substances are fraught with similar difficulties as to method, and are not different as regards their quality. The increase in walking distance is highly variable, especially in the pentoxifylline studies. On average through each and all of the studies on both preparations, an increase of 45% (EGb 761) or 57% (pentoxifylline) in relation to initial values is here found. No differences in the documentation of efficacy and the clinical efficacy were discovered between the two substances, both of which are registered as effective substances in the treatment of peripheral arterial occlusion (pAO) in accordance with the Federal German Drugs Law (Arzneimittelgesetz, AMG) of 1976.

[Methods and results of physiotherapy in stage II arteriopathies (author's transl)]. / Méthodologie et résultats de la rééducation des artériopathies au stade II.

Physical training represents the oldest known treatment for arterial claudication. One can appreciate its results, during a stay in a rehabilitation center, by measuring the walking distance (WD) every week under standardized conditions. The results of the treatment are less good for proximal obliterations than for peripheral ones and for bilateral than for unilateral ones. To appreciate the intervention of hemodynamical factors, the comparison of WD after 4 to 6 weeks of training, and Doppler pressures at the ankle (AP) is performed. It only shows a WD-AP correlation on patients showing unilateral arteriopathies and who's pressures are comprised between 60 and 100 mmHg. The improvement of walking technic appear as an important factor of progress of WD. In our experience physical training is a sufficient and satisfactory treatment for 3/4 of claudicating patients.

[Doppler-ophthalmomanometry in patients with obstruction of the carotid arteries]. / Doppler-Ophthalmomanometrie bei Patienten mit Obstruktionen im Karotisstrombereich.

A novel noninvasive method to determine simultaneously ophthalmic artery pressure (OAP) and flow direction based on Doppler ultrasound principles is presented: ophthalmomanometry-Doppler (OMD). Studies performed on 25 angiographically proven normal subjects with direct recording of the internal carotid artery pressure (ICP) and indirect determination of the brachial artery pressure (BAP) demonstrated that OAP values assessed by the OMD device are highly correlated with simultaneous ipsilateral intraarterial systolic ICP measurements (r = 0.95, n = 10) and with simultaneous recordings of the BAP (r = 0.88, n = 15). In 50 patients presenting angiographically occlusions and 52 patients presenting angiographically stenoses (greater than 60%) of the carotid artery the measured Doppler ophthalmic pressure index (OPI = ratio of the ophthalmic to systemic blood pressure) was lower ipsilateral to an occlusion (0.46 +/- 0.08) than ipsilateral to a stenosis (0.54 +/- 0.08; p less than 0.001) of the carotid artery. In both it was clearly diminished compared to normal values (0.68 +/- 0.04; p less than 0.001). In carotid artery occlusions, the ipsilateral OPI was 0.46 +/- 0.06 for antegrade (n = 17) and 0.46 +/- 0.09 for retrograde (n = 28) ophthalmic artery flow. In carotid artery stenoses, the ipsilateral OPI was 0.55 +/- 0.07 for antegrade (n = 41) and 0.48 +/- 0.06 for retrograde (n = 9) ophthalmic artery flow (p less than 0.01). It is concluded that in carotid occlusions presenting a longer disease history extra-intracranial collateralisation via the ophthalmic artery are as efficient as a functional circle of Willis.