Cerebrovascular occlusive disease: hydatidosis

We reviewed six patients with cerebral hydatid embolism from the heart. Although hydatid disease is becoming less common in the world as a whole, it should be considered in the differential diagnosis of embolic stroke in children, especially in the infested areas where hydatidosis is endemic.     

Endoluminal treatment of vascular occlusive disease

The logical desire to avoid major cutaneous incisions and surgical dissection in the treatment of vascular occlusive disease has, in recent years, led to a surge of new therapeutic options whereby access to the diseased blood vessel is obtained via a distant site and treatment is effected from within the vessel. Such endoluminal treatment modalities include thrombolysis, balloon angioplasty, atherectomy, stenting, and stent grafting. For the purpose of this surgically oriented article, the latter two techniques are discussed.     

Extra-anatomic bypass for aorto-iliac occlusive disease in octogenarians

Effect of verapamil post-treatment (0.2 mg/kg bolus, followed by 0.01 mg/kg/min infusion) on the functional and metabolic changes of the heart after a brief regional ischemia (20 min) followed by 1 hr of reperfusion was studied in open-chest pentobarbitone anaesthetized dogs. In control dogs 1 hr of reperfusion failed to cause any improvement of depressed myocardial contractility (LVdP/dtmax and LVEDP) caused by 20 min of ischemia, which confirmed the earlier reported phenomenon of 'Stunned Myocardium'. Myocardial ischemia caused a significant loss of high-energy phosphate (HEP) content of the affected myocardium (ATP decreased by 60% and CP decreased by 75% of non-ischemic level). Following 1 hr of reperfusion, myocardial ATP was not replenished, though creatine phosphate became near normal. When verapamil was administered just before reperfusion, it showed a profound beneficial effect on the incidence of fatal reperfusion arrhythmias. At the end of 1 hr of reperfusion in this group, the recovery of the myocardial contractility was incomplete, but a significant replenishment of the myocardial HEP content was observed. Thus verapamil post-treatment can prevent reperfusion-induced myocardial injury but functional recovery may be delayed due to the drug's inherent direct myocardial depressant effect.     

Circadian variation of skin perfusion in arterial occlusive disease

OBJECTIVE: To evaluate standing, percutaneous, ultrasound-guided, transthoracic liver biopsy in mares, and transabdominal laparoscopically-guided, liver biopsy under general anaesthesia in foals, as techniques for obtaining tissue for assessment of copper status. The techniques were evaluated with respect to ease of use and effect on the animal. PROCEDURE: Twenty of 24 Thoroughbred mares and 21 of their foals were biopsied. The animals were part of a larger study of the effect of copper supplementation on copper status and the prevalence of developmental orthopaedic disease. Livers were also collected from unrelated horses and sampled to investigate the variability in the distribution of copper in liver tissue. RESULT: The biopsy technique caused no lasting effect on the mares, but there was an increased risk of viscus penetration associated with taking multiple biopsy cores. The use of ultrasonography to scan the target area for the liver identified four cases that were not appropriate candidates for liver biopsy, because of large intestine being located in the biopsy area. In the foals there were no serious postoperative adverse effects, nor was there any evidence of problems caused by the procedure when the abdomen was examined post-mortem at 5 months of age. In livers collected to investigate the variability of copper concentration, copper appeared to be relatively evenly distributed through the liver. CONCLUSION: Standing, percutaneous, ultrasound-guided, transthoracic liver biopsy in mares, and transabdominal, laparoscopically-guided, liver biopsy under general anaesthesia in foals are convenient procedures for obtaining liver tissue for assessing copper status in horses. The use of ultrasound to identify liver tissue is recommended, especially in older mares.     

Effects of garlic coated tablets in peripheral arterial occlusive disease

For the first time, a weak clinical efficacy of a 12-week therapy with garlic powder (daily dose, 800 mg) is demonstrated in patients with peripheral arterial occlusive disease stage II. The increase in walking distance in the verum group by 46 m (from 161.0 +/- 65.1 to 207.1 +/- 85.0 m) was significantly higher (P < 0.05) than in the placebo group (by 31 m, from 172.0 +/- 60.9 to 203.1 +/- 72.8). Both groups received physical therapy twice a week. The diastolic blood pressure, spontaneous thrombocyte aggregation, plasma viscosity, and cholesterol concentration also decreased significantly. Body weight was maintained. It is quite interesting that the garlic-specific increase in walking distance did not appear to occur until the 5th week of treatment, connected with a simultaneous decrease in spontaneous thrombocyte aggregation. Therefore, garlic may be an appropriate agent especially for the long-term treatment of an incipient intermittent claudication.     

Epidemiology of atherosclerotic peripheral arterial occlusive disease in Hong Kong

Incubation of bovine liver mitochondrial rhodanese in dilute, reducing solutions at temperatures ranging between 30 and 45 degreesC conduced to a rapid loss of enzymatic activity. This inactivation was substantially reduced in the presence of millimolar concentrations of alkali metal ions, divalent cations (including Mg2+, Ca2+, and Ba2+) were ineffective. The extent of protection afforded by monovalent cations was highly dependent on their ionic radii, with K+ and Na+ ions being the most effective protective agents. The protection afforded by a number of anions, including thiosulfate, could be totally ascribed to the presence of the accompanying monovalent cation. The overall results indicate that K+ and Na+, at concentrations and temperatures within the physiological range, substantially contribute to the stabilization of the functional structure of rhodanese.     

Improved walking economy in patients with peripheral arterial occlusive disease

The effect of exercise rehabilitation on the oxygen cost of ambulation in patients with peripheral arterial occlusive disease (PAOD) was evaluated with specific emphasis on the effects of exercise rehabilitation on the slow component of VO2. Because the slow component of VO2 represents an increase in VO2 despite constant-intensity exercise, it can profoundly affect the relative energy cost of exercise in individuals with a low functional capacity. Twenty-six patients with intermittent claudication performed treadmill walking at 2.0 mph/0% grade for 20 min or until maximal claudication pain before and after 4 months of rehabilitation. The slow component of VO2 during the treadmill test was defined as the difference between the end-exercise VO2 and the VO2 observed at minute 3. Ankle/brachial systolic pressure index (ABI) was measured before and immediately following the exercise test. Rehabilitation consisted of 3 d x wk(-1) of treadmill walking for 15-30 min at 60-70% of VO2peak. The slow component of VO2 and end-exercise VO2 at pretraining (0.75 +/- 0.90 and 11.12 +/- 2.10 mL x kg[-1] x min[-1]) were significantly reduced after 4 months of exercise rehabilitation (-0.07 +/- 1.11 and 10.07 +/- 1.80 mL x kg[-1] x min[-1]; P < 0.05). Exercise rehabilitation also significantly (P < 0.05) increased the post-exercise ABI (pre-rehabilitation = 0.36 +/- 0.26, post-rehabilitation = 0.43 +/- 0.25). These data suggest that 4 months of exercise rehabilitation: 1) improves walking economy in PAOD patients because of a decreased slow component of VO2, and 2) increases post-exercise ABI.     

Predilection of occlusive disease for the left iliac artery

Eighty-six consecutive patients operated on for atherosclerotic occlusion of the aortoiliac segment were examined regarding the severity of the disease in the left or right iliac arteries. Sixty-nine percent of 78 patients were found to have predominantly more severe lesions on the left side. A study of the geometric anatomy of the aortoiliac region in 14 male and 12 female cadavers revealed that the right common iliac take-off angle was wider than the left and the radius of curvature of the right osculating circle at the aortoiliac bifurcation was smaller than the left, with the asymmetry of the region being much more marked in males than in females. The predilection of occlusive disease for the left iliac artery is explained on the basis of these differences in local geometric anatomy and their effect on the local hemodynamics.     

Reconstruction of large veins for nonmalignant venous occlusive disease

To evaluate the effectiveness of venous grafting, we reviewed the management and clinical course of 28 patients (21 males and seven females) who underwent 29 reconstructions of large veins for benign disease. There were 12 patients with superior vena cava (SVC) syndrome, two with subclavian vein thrombosis, and 15 with occlusion of the inferior vena cava (IVC) or iliac veins. One of these patients underwent both IVC and SVC reconstructions. Reconstruction of the SVC was performed with spiral saphenous vein graft (SSVG) in nine patients and expanded polytetrafluoroethylene (ePTFE) in three. All seven straight SSVGs had documented patency at a median of 7 months (2 weeks to 5 years) after reconstruction. Six patients had complete relief of symptoms. Two patients with bifurcated SSVG had early occlusion of one graft limb. Two of the three ePTFE grafts needed early thrombectomy. One graft reoccluded at 6 months and two were patent at 2 and 5 years. The two subclavian vein reconstructions with axillary-jugular ePTFE grafts with an arteriovenous fistula had documented early patency. Both patients had rapid resolution of symptoms. The IVC or iliac vein was reconstructed with ePTFE graft in 11 patients, SSVG in three, and Dacron in one. A femorofemoral arteriovenous fistula was added in eight patients with ePTFE grafts. Seven of the 11 ePTFE grafts had documented patency at the last follow-up (median 9 months; range 2 weeks to 5 years). None of the three SSVGs had documented long-term patency. The one Dacron cavoatrial graft occluded at 3 years. A straight SSVG continues to be our first choice for SVC replacement. Short, large-diameter ePTFE grafts perform the best in the abdomen. Femorocaval or long iliocaval grafts need an arteriovenous fistula to maintain patency. Long-term patency after closure of the fistula is still unknown. Femorocaval grafts with poor venous inflow have limited chance of success. Failed or failing grafts may be salvaged by early thrombectomy. Venous reconstruction to treat selected patients with symptoms with large vein occlusion continues to be a viable option.     

Reduction by indobufen of neutrophil activation in peripheral arterial occlusive disease

We evaluated the effectiveness of indobufen administration in reducing neutrophil activation in a clinical model of ischemia-reperfusion. Thirty stable patients with intermittent claudication due to occlusive peripheral arterial disease of the leg were randomly assigned to two groups. Patients in group I were treated with indobufen [200 mg orally twice daily (p.o. b.i.d.) for a week]; patients in group II received a placebo. Both groups of patients were submitted to standardized treadmill exercise until onset of claudication. Plasma levels of thromboxane B2 (TxB2) and 6-keto-prostaglandin F1alpha(6-k-PGF1alpha) neutrophil filterability, and neutrophil activation (by nitro-blue tetrazolium test) were assessed in blood samples from the femoral vein draining the ischemic leg. The values were obtained at rest and 5, 30, and 60 min after onset of claudication. Urinary albumin excretion was measured at rest and 1 h after onset of claudication. Plasma levels of TxB2 and 6-k-PGF1alpha increased significantly in the placebo group 5 min after onset of claudication, whereas only a slight nonsignificant increase was observed in the indobufen-treated group at the same timepoint.     

Most frequent ways of the collateral circulation in occlusive coronary artery disease

By comparison of the sectional area of the fetal head of the fronto-occipital level in the height of the biparietalic diameter and the cross sectional area of thorax in the level area of the ventrical it was tried to determine the exspected birth weight. A mean deviation of 8,9% was found. Below a birth weight of 2500 g the presented calculation is only valid to some extend as in these cases the dominance proved in fetal development grounds of the head of the fetus becomes apparent.     

Selection of surgical approaches in the treatment of aortoiliac arterial occlusive disease

31 patients with aortoiliac occlusive disease with or without infrainguinal occlusion was treated with thromboendarterectomies, aortoiliac or aortofemoral arterial bypasses, extra-anatomic bypasses and sequential arterial bypasses in the past 5 years. The results were satisfactory. The surgical mortality was 3.2%, the primary 5-year patent rate was 84.2%, and the secondary 5-year patent rate was 96.5%. We emphasize the value of ABI to indicate arterial reconstruction.     

Tibial and peroneal bypass in severe occlusive disease of the lower extremities

Symptomatic arteriosclerotic occlusive disease involving the femoral and proximal popliteal arteries is currently best treated by reversed autogenous saphenous vein bypass graft. Severe occlusive disease frequently includes the popliteal and/or origin of the trifurcation vessels with reconstitution of one or more of the vessels in the lower leg. We have used distal bypass 97 times in 90 patients during the past decade. There was only one postoperative death in the series in spite of the advanced age and concurrent disease in the majority of the patients. Our indications for operation continue to be relief of pain or salvage of an extremity. We rely on high quality preoperative angiograms for selection of vessels to receive the bypass. The posterior tibial artery was used in 63 of the cases, while the anterior tibial and peroneal were used in 24 and 10 cases, respectively. There were 11 immediate inhospital failures in this series of 97 cases requiring amputation in five. Three additional patients had amputations during the ensuing several months. Of the 85 grafts functioning at the time of discharge from the hospital, 16 or (18.8%) failed during the first years. Grafts that remained patent for one year have a high incidence of long term patency which is in keeping with other reported series.     

Large vessel occlusive disease associated with CREST syndrome and scleroderma

OBJECTIVES: To report the cases of three patients with CREST syndrome and one patient with diffuse scleroderma who had severe macrovascular disease and only minimal vascular risk factors. METHODS: The medical histories, physical examinations, and results of clinical investigations were reviewed in four patients. RESULTS: These four patients had severe morbidity from macrovascular disease of the arms and legs in the presence of minimal underlying vascular risk factors. These patients represent 11% of the women with scleroderma seen at our hospital since 1974. This is a greater than threefold increase above the expected proportion of symptomatic vascular disease seen in population studies. In the patients with CREST syndrome, large vessel disease was first seen more than 10 years after the onset of Raynaud's phenomenon, which was the first manifestation of the disease. A pathological specimen of the ulnar artery from one patient showed severe luminal narrowing by an acellular material with no evidence of atheroma. CONCLUSIONS: These cases suggest an association of both the CREST syndrome and scleroderma with macrovascular disease.     

Total aortic arch reconstruction for multiple great vessel occlusive disease

The immune system involvement in psoriasis has been documented by the presence of activated T-cells both in peripheral blood and in psoriatic skin lesions and by the intervention of cytokines in the inflammatory process. On this basis, we have undertaken a study in order to examine, in addition to activation markers such as CD25 and CD54 (ICAM-1) on peripheral blood mononuclear cells (PBMNCs) surface, serum levels of soluble interleukin (IL)-2 receptor (sIL-2R), soluble ICAM-1 (sICAM-1), soluble CD4 (sCD4), soluble CD8 (sCD8), beta 2-microglobulin and fibronectin (FN) in psoriatic patients analyzed both in acute and remission phase obtained by topical therapy alone. Our results show that PBMNCs expressing IL-2 receptor (CD25) were increased both in percentage and absolute number in respect to controls, and were not modified after remission. On the contrary, the significantly higher number of CD54+ lymphocytes evaluated in acute psoriasis, showed a reduction during the remission phase, even if the values persisted higher than controls. Serum levels of sIL-2R, sICAM-1, sCD4, sCD8 and beta 2-microglobulin were significantly higher than controls both in acute and remission phase; only FN levels were found to be lower, in patients evaluated both in acute psoriasis and after therapy, in respect to normal donors. On the whole, these results seem to indicate the persistence of both cellular and soluble activation markers even in psoriasis remission phase; in this light, we can suppose that topical therapy alone is not able to efficiently down-regulate activation mechanisms involved in the pathogenesis of the disease.     

Long-term results after open and semiclosed thrombendarterectomy for aortoiliac occlusive disease

OBJECTIVES: This study reviews the long-term results of 514 aortoiliac thrombendarterectomies (TEA's). DESIGN: A prospective study in a major university hospital in Switzerland. SUBJECTS: 353 male and 62 female patients with aortoiliac occlusive disease. Operative indications: disabling claudication (n=334), rest pain (n=44), and gangrene (n=37). METHODS: Open and semiclosed TEA's were performed on 167 and 347 limbs, respectively. Follow-up was continuous and complete in 97.1 % of patients over a period of more than 15 years. RESULTS: The overall life-table patency rate at 5, 10, and 15 years postoperatively were 93.4 %, 90.4 %, and 84.2 %, respectively. Fifteen years postoperatively, the patency rate of 92.3 % after open TEA was significantly higher (p<0.04) than after semiclosed TEA (79.5 %). However, similar patency rates of 69.5 % and 69.8 % were observed 20 years postoperatively. Further significant prognostic factors on patency were: anatomic localization (p<0.004), preoperative stage of arterial occlusive disease (p<0.008), and gender (p<0.007). Patient's age did not influence the outcome in terms of patency. Hospital mortality rate was 1.2 %. Early obstruction occurred in 2.2 %, leading to subsequent early amputation of 1.4 % and reoperations in 1.2 %. The long-term actuarial survival rates of the patients were 55 %, 36 %, and 18 % after 10, 15, and 20 years postoperatively. CONCLUSION: Both open and semiclosed TEA give highly satisfactory long term results in aortoiliac occlusive disease with a low morbidity and low mortality.