Intraoperative control following femorodistal revascularization: angioscopy is superior to angiography

Intraoperative angioscopic control was performed in an early series of 27 patients undergoing peripheral vascular surgery. The majority were complex or re-do operations; reversed saphenous vein and PTFE-grafts were used as bypass material exclusively. Angioscopic findings were compared to conventional angiography with respect to the detection of technical problems leading to further surgical procedures. Angioscopy was feasable in 92.5%, it failed twice due to irrigation problems, which was before we used a dedicated angioscopy roller-pump. In 6 patients relevant findings requiring further surgical manipulations were only detected angioscopically, in 2 patients such findings were detected by angioscopy as well as by angiography. Such findings included technical problems (graft rotation [n = 1], anastomotic narrowing [n = 2]), balloon catheter injuries after thromboembolectomy (n = 2) and residual thrombi after local thrombectomy (n = 3); 5 of these patients had undergone previous vascular procedures in the same operation field. After local correction (n = 5) or placement of a new bypass (n = 3) there was no early graft failure. This early angioscopic experience confirmed previous reports that satisfactory visualization and specific recognition of angiographically unsuspected problems after peripheral reconstructions can be obtained by intraoperative angioscopic control. This was seen very distinctively in more complex and re-do operations, which we see as the cases most needing routine angioscopic control.     

Thrombolytic therapy in an isolated limb

Intraoperative thrombolytic therapy is a useful adjunct to balloon catheter thromboembolectomy for treatment of acute embolism or thrombosis, but the technique is frequently limited by incomplete thrombolysis and systemic hemorrhage. In an attempt to improve results and reduce complications of conventional thrombolytic therapy, urokinase was infused into a limb that was isolated with a tourniquet. This isolated limb perfusion technique was initially developed in an animal model and subsequently used for limb salvage in patients who failed thromboembolectomy. The animal model demonstrated that a fibrinolytic state could be achieved and isolated to the extremity, even when using extremely high dose (20,000 to 50,000 IU/kg) of thrombolytic agents. The fibrinogen level was unmeasurable and the prothrombin, partial thromboplastin, and thrombin times were significantly prolonged in the isolated limb (p < 0.001), whereas no changes occurred in these parameters in the systemic circulation. In seven patients, streptokinase (27,000 to 200,000 IU) and urokinase (150,000 to 300,000 IU) were infused into isolated extremities after thrombectomy alone had failed to restore blood flow. All extremities showed improved perfusion after thrombolytic therapy and five remained viable 6 months after treatment. There were no systemic bleeding complications despite two patients having undergone major operations within 6 days. Tourniquet isolation of the limb can achieve extremely high concentrations of thrombolytic drugs while reducing the potential for systemic fibrinolysis and allows lysis of previously inaccessible thrombus.     

Effect of anti-insulin serum on the hepatic lipid metabolism of BHE rats

Vascular injury or occlusion from intra-aortic balloon pumping (IABP) that results in actual or potential limb ischemia occurs more frequently than reported. In a series of 79 IABP patients, 36 lived long enough to have the balloon catheter removed; thirteen (36%) of them had vascular complications. The complications were in three patients with an injury at the insertion site, eight patients with arterial thromboses, and two with arterial occlusion by the large balloon catheter. Local artery revision, thrombectomy alone, or thrombectomy with femorofemoral cross-over grafting was required in 11 patients. Femorofemoral crossover graft was utilized when arterial occlusion would have ordinarily required premature balloon removal or when immediate arterial occlusion by the catheter was recognized at the time of balloon insertion. This was preferable to transferring, replacing, or discontinuing IABP, since the same factors that led to thrombosis in the first place would have eventually come into play again. Patients should be observed frequently and have Doppler limb pulse determinations every four hours to avoid ischemic catastrophies. Proper IABP weaning and the use of a Fogarty catheter at the time of balloon removal is mandatory to prevent complications. Femorofemoral crossover graft is indicated for ischemic limbs when IABP must be continued.     

The value of intraoperative angiography for surgical treatment of cerebral arteriovenous malformations in eloquent brain areas

Intraoperative digital subtraction angiography (DSA) allows intraoperative assessment of outcome of cerebral arteriovenous malformations (AVM). This study reports on 21 patients with AVMs in eloquent areas of the brain extirpated between July 1995 to March 1998. Extirpation was always followed by intraoperative DSA. Intraoperative angiography disclosed an occult residual nidus in 4 cases (19%). Complete extirpation of the AVM was achieved in all cases. Following surgery the neurological condition improved in 15 cases (71%), remained unchanged in 5 (24%), and worsened in 1. There were no secondary postoperative haemorrhages, nor complications related to the angiography. These results indicate that intraoperative DSA should be considered in the course of surgical treatment of cerebral AVMs in eloquent areas of the brain.     

Levo-Alpha Acetyl Methadol (LAAM). Its advantages and drawbacks

Although the histologic effects of balloon catheter thromboembolectomy in arteries are well described, little is known about its effects on arterialized vein grafts. A chronic canine model was used to compare the intimal hyperplasia that develops following balloon catheter thrombectomy versus thrombolytic therapy when each treatment was used to open experimentally occluded reversed autogenous vein grafts. Eleven of 12 dogs survived to the time of graft thrombosis and treatment. Ten grafts in one group of animals were treated with shear force-controlled balloon catheter thrombectomy, and eleven grafts in another group of animals were treated with infusion of urokinase (average 355, 833 IU/graft). Explantation and histologic evaluation was performed 5 weeks after treatment. Data were evaluated at comparable anatomic locations. These studies demonstrated the development of intimal hyperplasia in both groups with no statistically significant differences in the intimal thickening between the two treatment groups. It is hypothesized that vessel wall damage occurs at the time of thrombosis with the adherence of thrombus to the wall, and that this may be as important in producing intimal hyperplasia as the effects of carefully performed balloon thrombectomy or lytic therapy.     

Single dose medication vial packaging deficiencies

OBJECTIVES: Technical success and early outcome of modified surgical techniques integrating interventional procedures for iliac recanalisation performed through an incision in the groin. MATERIALS: Sixty-one consecutive iliac arteries in 59 patients with long occlusions in 16, occlusions of the common iliac in 11, occlusions of the external iliac in 24 and multiple stenoses of the iliac in 10 cases underwent semiclosed recanalisation through a groin incision. METHODS: Passage of the lesion by guidewire permits retrograde ring-stripper endarterectomy over the wire as a guiding splint or thrombectomy with a double lumen balloon catheter. Residual lesions are corrected by balloon or stent angioplasty. Adequate outflow is established by femoral patch plasty. RESULTS: Conversion to a standard operation was required in 10 limbs (failure to recanalise the lesion in nine, rupture after angioplasty in one). Initial technical success was achieved in the remaining 51 limbs (recanalisation by ring stripper endarterectomy in 36, thrombectomy in 14, both in six, additional intraoperative angioplasty in 42). Five postoperative thromboses were successfully treated by a combined surgical and interventional approach accounting for a 1-month 100% secondary patency. CONCLUSION: Iliac recanalisation through the groin by modified ring stripper endarterectomy or modified thrombectomy in combination with intraoperative angioplasty is a safe and effective procedure. Long-term results are required to evaluate the procedure.     

Damage to the vessel wall by the Fogarty balloon catheter

Thromboembolectomy with the Fogarty balloon-catheter is a well-established surgical therapy for the treatment of acute ischemia with generally good results. However, arterial injuries caused by balloon embolectomy occur in up to 6%. The different types of injury are mentioned, the role of myointimal hyperplasia as a result of endothelial denudation is discussed. We conclude that after balloon-catheter thromboembolectomy an early angiographic control should be performed and repeated 3 months postoperatively.     

Medial temporal lobe atrophy in stroke patients: relation to pre-existing dementia

BACKGROUND: To investigate the role and impact of multiplane transesophageal echocardiography during thrombectomy in the inferior vena cava or the right atrium. EXPERIMENTAL DESIGN: Retrospective. SETTING: A university hospital. PARTICIPANTS: Four patients who underwent removal of tumor thrombus in the inferior vena cava (IVC) or the right atrium. INTERVENTIONS: The medical records of 4 patients and videotapes of these intraoperative transesophageal echocardiography examinations were reviewed. RESULTS: Before thrombectomy, multiplane transesophageal echocardiography (MTEE) provided excellent IVC long axis view, which offered precise recognition of the cephalic extent of tumor, extent of caval occlusion, characterization of the tumor head. During surgery, MTEE could provide continuous monitoring of cardiac function, cardiac volume, and pulmonary embolism. Moreover, MTEE could provide the useful images of a cannula or the caval occlusion balloon catheter, which facilitated removal of neoplasm extending into the IVC. CONCLUSIONS: We presented four surgical cases, in which the removal of the tumor extended into the inferior vena cava or the right atrium using MTEE. MTEE could provide valuable information such as excellent images of the tumor, cardiac function, the position of a cannula or the caval occlusion balloon catheter. These findings could improve the anesthetic management of the patients, as well as the surgical approach and technical maneuvers, and facilitate removal of neoplasm into the IVC.     

Transbrachial arterial catheter angiography. Technique, indications, complications

In a large group of patients, most of whom were attending a department of vascular surgery, who underwent arterial digital subtraction angiography (DSA), a transfemoral approach was not possible in 9%. Therefore in 142 cases transbrachial arterial angiography was electively performed with 4-F or 5-F catheters. This method proved to be a safe and reliable alternative, though the examination technique was more demanding and the complication rate somewhat higher. It offers clear advantages over a transaxillary or translumbar approach. Special attention is paid to the role of transbrachial arterial DSA in evaluating the descending aorta and the peripheral outflow in the legs and to its usefulness in certain angioplasty manoeuvres.     

Intracranial vascular stenosis and occlusion: comparison of 3D time-of-flight and 3D phase-contrast MR angiography

We compared the value of 3D time-of-flight (TOF) and phase-contrast (PC) MR angiography (MRA) for detection and grading of intracranial vascular steno-occlusive disease. Unenhanced 3D-TOF MRA and 3D-PC MRA (30-60 cm/s velocity encoding) were performed at the level of the circle of Willis in 18 patients, mean age 56 +/- 10 years. Postprocessed images using a maximum-intensity projection reconstruction with multiple targetted projections were analysed. A total of 126 vessels was assessed by PC MRA and 143 by TOF MRA, with digital subtraction angiography (DSA) in 15 patients and/or transcranial Doppler sonography (TCD) in 18 as a standard. Two blinded readers reviewed the MRA, DSA and TCD examinations retrospectively. On DSA and/or TCD the two observers found 32 and 28 steno-occlusive lesions. 3D-TOF MRA was more sensitive than 3D-PC MRA (87% and 86% vs. 65% and 60%) and had a higher negative predictive value (96% vs. 89%). Correct grading of stenoses was achieved in 78 % by 3D-TOF and 65% by 3D-PC MRA.     

Comparison of four media for the isolation of Aspergillus flavus group fungi

By digital subtraction angiography (DSA), the authors made observations on 108 normal ophthalmic arteries in 80 patients with regard to the origins, courses, branching, morphology and anastomoses of the vessels. The merits and demerits of DSA in observing the ophthalmic artery were discussed.     

Combined intraoperative retrograde stent implantation and thrombendarterectomy of the carotid artery

HISTORY AND CLINICAL FINDINGS: A 63-year-old man developed recurrent transitory ischaemic episodes of vertigo and weakness in the legs 6 weeks before admission. 3 weeks later he had a left amaurosis fugax. A stenotic murmur was heard over the left carotid artery. INVESTIGATION: Intraarterial digital subtraction angiography of the arteries to the head revealed occlusion of the right internal carotid artery (RICA) and marked narrowing at the origin of the left common carotid artery (LCCA), which could not be passed by catheter. TREATMENT AND COURSE: As a catheter could not be passed into the LCCA, a stent was at operation placed retrogradely into it. Intraoperative angiography showed subtotal stenosis of the left ICA, which was treated by thrombendarterectomy and dacron patch-plasty. The postoperative course was without complication and the patient was free of symptoms. Follow-up angiography was unremarkable. CONCLUSION: If a stenosis of the carotid artery cannot be passed by catheter, intraoperative retrograde placement of a stent is an alternative to percutaneous antegrade transluminal angioplasty or surgical bypass.     

Digital subtraction rotational angiography for aneurysms of the intracranial anterior circulation: injection method and optimization

PURPOSE: To optimize parameters of rotational angiography for examination of the internal carotid circulation; to compare rotational angiography with standard digital subtraction angiography (DSA) in the evaluation of aneurysms of the intracranial internal carotid circulation; and to determine tolerance and safety limits of prolonged internal carotid injection angiography. METHODS: Rotational angiograms were obtained during injection of the internal carotid circulation as part of the clinical angiographic evaluation of aneurysms in 41 patients. Injection rates, X-ray delays, and fields of view were studied retrospectively. Findings at rotational angiography and standard DSA were compared. Nonionic contrast material was injected over 6 seconds, and patients were studied before and after prolonged injection angiography by physical and laboratory examination, including measurement of blood pressure, pulse, and intracranial pressure. RESULTS: Vascular conspicuity was equivalent at carotid injection rates of 4 and 5 mL/s delivered over 6 seconds. At 3 mL/s, more image manipulation was required to see small vascular structures. One-second X-ray delay combined with 6-second injection duration provided the best arterial depiction of intracranial vessels from start to end of rotational angiography. Maximal rotational resolution was with a 17-cm field of view. Identification of aneurysms and small vessels was equivalent at all injection rates. Aneurysm detection was equivalent with rotational angiography and DSA. In 9 of 31 aneurysms, the neck was defined more clearly with rotational angiography than with DSA, compared with 2 of 31 that were seen better with DSA. Aneurysms of the intracranial internal carotid circulation were seen with rotational angiography and not DSA in 12 of 41 cases. No change was noted in clinical or laboratory findings. CONCLUSION: Rotational angiography provided better definition of the aneurysmal neck and greater clarity of aneurysms than did DSA; it also improved the level of confidence in predicting the presence or absence of aneurysms, especially in the anterior communicating artery; however, in our small series it did not significantly increase the detection of aneurysms. Prolonged injection angiography was well tolerated in all patients.     

Mycotic aneurysm of the external carotid artery

Mycotic aneurysms of the extracranial carotid arteries are extremely rare. A case is reported of a false aneurysm of the left external carotid artery. This developed secondary to cervical lymphadenitis which did not settle with high dose antibiotic therapy. The diagnosis was made on investigation with carotid doppler ultrasound and confirmed with computerized tomography. Digital subtraction angiography was performed to highlight the vascular anatomy. In addition percutaneous balloon catheter control of blood flow in the external carotid artery was used as an adjunct to surgical management.     

Comparison of two-dimensional MR digital subtraction angiography of the lower extremity with x-ray angiography

PURPOSE: To perform a preliminary evaluation of the diagnostic accuracy of contrast-enhanced, two-dimensional (2D) magnetic resonance (MR) digital subtraction angiography (DSA) of the lower extremity by comparison with x-ray angiography (XRA). MATERIALS AND METHODS: Forty lower extremities in 22 patients were imaged at multiple levels with both XRA and 2D MR DSA. Images were retrospectively analyzed by three radiologists in a randomized blinded manner. Seventeen vascular segments were graded as an insignificant lesion, a significant lesion, or as an occlusion. With the use of segments well depicted with XRA as the gold standard, the sensitivity, specificity, and accuracy of 2D MR DSA, as compared with XRA, were evaluated. The McNemar-Stuart-Maxwell test was performed to determine the significance of any differences found. RESULTS: Three hundred eighty-three arterial segments were evaluated with both techniques. Three hundred one segments were well depicted with XRA. There was no significant difference between 2D MR DSA and XRA for assessing the degree of occlusive disease in these 301 segments (.25 < P < .5). The sensitivity, specificity, and diagnostic accuracy of 2D MR DSA were found to be 90%, 98%, and 93%, respectively. CONCLUSION: Two-dimensional MR DSA is an accurate method for assessing arterial lesions in the lower extremity.     

Magnetic resonance angiography in patients with acute stroke treated by local thrombolysis

Although magnetic resonance angiography (MRA) is accepted for showing chronic intracranial stenotic or occlusive lesions, the method has not been practically examined in patients with acute cerebral ischaemia. We carried out three-dimensional time-of-flight MRA in six patients with acute ischaemia treated by local thrombolysis, and compared the findings with those of digital subtraction angiography (DSA). In all patients, MRA before thrombolysis clearly demonstrated the occluded arteries, which corresponded precisely to those shown by DSA. In four patients with complete recanalisation of the occluded vessels after thrombolysis, the recanalisation could be demonstrated by postoperative MRA. In one patient with reocclusion of the recanalised artery, repeat MRA also demonstrated the reocclusion, confirmed by DSA. These results suggest that MRA may be helpful for noninvasive investigation before and after thrombolysis.     

Restenosis of peripheral stents and stent grafts as revealed by intravascular sonography: in vivo comparison with angiography

OBJECTIVE: Our objective was to compare intravascular sonography with digital subtraction angiography (DSA) in the assessment of luminal dimension and morphologic features of endovascular stents and stent grafts. MATERIALS AND METHODS: Thirty-seven pelvic and 24 femoral stents (12 Wall-stents; 27 covered and 22 uncovered nitinol stents) in 50 patients were evaluated 15 +/- 10 months after implantation by DSA and intravascular sonography. The degree of maximum instent restenosis as revealed by DSA and intravascular sonography was compared for each location. Morphologic features of the stents and stenoses were also assessed. RESULTS: Intravascular sonography and DSA correlated well (R2 = .96) in determining in-stent restenosis. In-stent restenosis was underestimated by 13% +/- 6% by DSA compared with intravascular sonography. Differences in determining in-stent restenosis with intravascular sonography and DSA were not associated with severity of stenosis or type of stent. Intravascular sonography revealed incomplete expansion of stents in 21 cases, whereas DSA revealed incomplete expansion of stents in seven cases. The intra- and interobserver variabilities in our study were 4% and 5%, respectively. CONCLUSION: In-stent restenoses are underestimated with DSA. Intravascular sonography is superior to DSA for detection of incomplete stent expansion.     

Role of pulse spray thrombolysis in acute ischemia of the extremities--comparison of results with the low dose technique of local thrombolysis, embolectomy and thrombectomy

BACKGROUND: The reported mortality of patients suffering from acute limb ischemia is in the range of 10% to 30%, as is the incidence of amputation in the survivors. MAIN PURPOSE: The evaluation of the pulse spray thrombolysis (PST) role in the treatment of acute extremity ischemia originating from thrombosis or embolism of native artery or bypass graft. The comparison of PST with low dose technique thrombolysis (LD), thrombectomy (TE) and embolectomy (EE). METHODS: Ninety nine consecutive patients were evaluated during a two year interval (1994-1996). PST, resp. LD, TE and EE were the method of choice in 22, resp. 11, 35 and 31 patients of average age 58.3 +/- 13.7; resp. 60.0 +/- 8.9; 74.2 +/- 11.7; 76.9 +/- 9.3 years. The native artery was occluded in 15 (68.2%), resp. 8 (72.7%), 31 (88.6%) and 30 (96.8%) patients with PST, resp. LD, TE and EE treatment. The vascular reconstruction was occluded in the rest of the cases. The lower limb extremity arteries were occluded in 20 (90.9%) of patients indicated for PST, 10 (90.9%) for LD, 33 (94.3%) for TE and 26 (83.9%) for EE. The contraindication for local fibrinolysis was severely ischemic limb in which viability was imminently threatened. RESULTS: PST was successful in 19 (86.4%), LD in seven (63.4%), TE in 13 (37.1) and EE in 27 (87.1%) patients. The failure of procedure required amputation in one patient (4.5%) with PST, one (9.1%) with LD, nine (25.7%) with TE-p < 0.001 and two (6.5%) with EE. The mortality was 4.5% (one patient), resp. 0%, 28.6% (10 patients)-p < 0.001 and 3.2% (one patient) in PST, resp. LD, TE and EE. The long term results were better if the successful local fibrinolysis was combined with percutaneous transluminal angioplasty (PTA), stent implantation or small vascular reconstruction. CONCLUSION: PST is the method of choice in the treatment of thrombotic or embolic occlusion of native artery or bypass graft in condition of good limb viability where there is no danger of time delay. EE is indicated in limb embolism where the viability of extremity is threatened. Thrombectomy alone has no place in the treatment of artery or bypass graft thrombosis.     

Comparison of angioscopy and angiography for monitoring infrainguinal bypass vein grafts: results of a prospective randomized trial

PURPOSE: This study was designed to determine whether, in primary infrainguinal bypass grafts in which only saphenous vein is used as the graft conduit, routine monitoring with intraoperative angioscopy can improve early graft patency as compared with standard monitoring with intraoperative completion angiography; and to delineate the advantages and disadvantages of these two modalities and their respective roles for the routine monitoring of the infrainguinal bypass graft. METHODS: A total of 293 patients undergoing primary saphenous vein infrainguinal bypass grafting were prospectively randomized and monitored with either completion angioscopy or completion angiography. Clinical parameters, indications for operation, graft anatomy, and configuration were evenly matched in both groups. Forty-three bypasses were excluded from the study after randomization, including 12 veins randomized to angiogram, deemed inferior, and prepared with angioscopy. RESULTS: In the 250 bypass grafts (angioscopy 128, angiography 122) there were 39 interventions (conduit, 29; anastomosis, 8; distal artery, 2), 32 with angioscopy and 7 with angiography (p < 0.0001). Twelve (4.8%) of the 250 grafts failed in less than 30 days, four (3.1%) of 128 in the angioscopy group and eight (6.6%) of 122 in the angiography group (p = 0.11 by one-sided hypothesis test). CONCLUSION: Although no statistical improvement in the proportions of failures in primary saphenous vein bypass grafts routinely monitored with completion angioscopy rather than the standard completion angiogram was demonstrated, the study delineates a trend that favors completion angioscopy for routine vein graft monitoring and demonstrates the advantages of angioscopy in preparing the optimal vein conduit.     

Urokinase treatment preserves endothelial and smooth muscle function in experimental acute arterial thrombosis

PURPOSE: Pharmacologic lysis or balloon thrombectomy are options to treat acute arterial thrombosis; however, little is known about their effects on functional changes in the arterial wall. The aim of this study was to determine function of the endothelium and smooth muscle in canine arteries revascularized after acute thrombosis with balloon thrombectomy or lytic therapy. METHODS: Acute thrombosis was obtained by bilateral proximal and distal ligation of 8-cm. segments of the femoral arteries in dogs. After 24 hours, the ties were removed and the arteries randomized to treatment groups: group 1, balloon thrombectomy (# 4 Fogarty balloon catheter at 60 grams linear shear x 1 pass, n = 7); group 2, untreated, tie removal only (n = 6); group 3, regional intra-arterial urokinase infusion (4000 U/min x 90 min, n = 6); group 4, regional intra-arterial carrier infusion (0.43 ml/min x 90 min, n = 6); group 5, unoperated normal vessels (n = 5). After treatment, the arteries were removed and endothelial and smooth muscle responses examined in organ chambers. Endothelial loss was graded with light microscopy of vessel rings from each animal by an observer blinded to the treatment group. Findings were confirmed with scanning electron microscopy. RESULTS: Treatment with urokinase did not alter endothelium-dependent relaxations or smooth muscle contractions compared with carrier infusion or untreated alone. Balloon catheter thrombectomy significantly reduced endothelium-dependent relaxations compared with all other groups in response to acetylcholine, bradykinin, and thrombin (p < 0.001). Contractions of smooth muscle in response to potassium chloride (60 mol/L) and phenylephrine (1 x 10-6 mol/L) were also reduced (p < 0.05). Rings from balloon thrombectomized arteries contracted in response to calcium ionophore A23187 (p < 0.001); these contractions were endothelium dependent and not reduced by indomethacin or blockade of endothelin A and B receptors. No significant differences in percentage of endothelial coverage between groups were assessed by light and electron microscopy. CONCLUSION: Thrombolysis with urokinase caused no or minimal abnormalities in endothelial and smooth muscle function. Endothelium present after balloon thrombectomy produces contractile factors. Although the duration and recovery of these abnormalities in function are unknown, these findings support preferential use of urokinase over balloon thrombectomy when possible in acute arterial thrombosis or embolism.