Enhanced expression of bcl-2 inhibits apoptosis in cultured human keratinocytes

Intravenous heparin followed by oral warfarin sodium is effective for preventing recurrent thromboembolism in patients who have pulmonary embolism or proximal vein thrombosis. The effectiveness of intravenous heparin depends on obtaining an adequate anticoagulant response early during therapy. A validated heparin protocol should be used to ensure that an adequate anticoagulant response is obtained as soon as possible. Low molecular weight heparin has the practical advantage that it does not require monitoring and dose finding. If thrombolytic therapy is indicated, it is safer for many patients to base management on the noninvasive diagnosis rather than performing pulmonary angiography. In patients suspected to have pulmonary embolism who have nondiagnostic lung scan and adequate cardiorespiratory reserve, serial noninvasive leg testing is a practical approach that avoids pulmonary angiography, identifies patients who have proximal vein thrombosis requiring treatment, and avoids the risks of anticoagulant treatment in the majority of patients.     

How often is thrombolytic therapy of deep pelvic-leg venous thrombosis indicated?

BACKGROUND: For patients with deep vein thrombosis new thrombolytic regimes are being proposed and demand evaluation in controlled studies. We tested prospectively, how many patients in internal medicine are candidates for thrombolysis. PATIENTS AND METHODS: All available patients with the diagnosis of deep vein thrombosis (DVT) in lower extremities who were admitted to the service of internal medicine in a medium-sized hospital during one year were prospectively evaluated for the indication of fibrinolysis therapy according to the established criteria. RESULTS: A total of 62 patients were enrolled. Fibrinolysis was not proposed in 25 patients aged over 70 years nor in another 9 patients in whom the thrombosis was restricted to calf veins. Nine additional cases had a recurrence of DVT (n = 4) or a history of more than 14 days. Among the remaining 19 patients, fibrinolysis was not performed in 11 because of advanced malignomas (n =4) or other diseases (n = 3) with limited life expectance, enhanced probability of haemorrhage (n = 3) and obvious non-compliance (n = 1). Eight patients were offered thrombolytic therapy, but 5 of them denied consent after being comprehensively informed. CONCLUSION: Obviously by far most of patients admitted to internal medicine for DVT are candidates for standard heparin therapy only.     

Recurrent renal vein thrombosis in a premature infant. Doppler ultrasound diagnosis and follow-up

Renal vein thrombosis (RVT) is a rare disorder in neonates. Early diagnosis is mandatory since immediate thrombolytic therapy favours prognosis. Our case report describes RVT demonstrated by Duplex Doppler Ultrasound. A possibly characteristic sequence of changes in the echogenicity of the renal parenchyma and in the Duplex Doppler flow pattern of the renal arteries could be found.     

Efficacy and safety of low molecular weight heparin in renal transplantation

BACKGROUND: Deep venous thrombosis (DVT) is a common problem with potentially devastating results in patients undergoing major surgical procedures. Certain renal transplant recipients are particularly at risk for allograft loss as a consequence of renal vein and artery thrombosis. Over the past few years, low molecular weight heparin has been well established as an accepted modality of treatment and prophylaxis of DVT. The efficacy and safety of low molecular weight heparin in the prophylaxis of DVT following renal transplantation in adults has not previously been reported. METHODS: Dalteparin was administered to 120 adult renal transplant recipients postoperatively at the Oregon Health Sciences University. RESULTS: No patient developed allograft arterial or venous thrombosis. One patient developed subclavian vein thrombosis. No bleeding complications were encountered, and side effects were very minimal. CONCLUSION: Prophylaxis with dalteparin is an effective and safe modality for the prevention of thrombosis in adult patients undergoing renal transplantation.     

Case report: acute renal vein thrombosis in patients with spinal cord injury and secondary amyloidosis

Chronic spinal cord injury, when complicated by chronic suppurative infections, has replaced chronic tuberculosis as a leading cause of secondary amyloidosis. Renal involvement with secondary amyloidosis is characterized by the presence of nephrotic range proteinuria and an increased incidence of renal vein thrombosis. Two cases of acute renal vein thrombosis associated with secondary amyloidosis in patients with spinal cord injury are presented. In both cases, a past history of extensive decubitus ulcerations and urinary tract infections preceded the development of nephrotic range proteinuria. In case 1, nonoliguric acute renal failure occurred after the development of acute bilateral renal vein thrombosis. The patient declined dialytic therapy and expired with uremia. In case 2, worsening renal function and increased proteinuria resulted after the development of acute unilateral renal vein thrombosis. These cases include the clinical and anatomic findings of acute renal vein thrombosis that occur as a complication of secondary amyloidosis. Acute renal vein thrombosis should be considered whenever an acute change in renal function or increase in proteinuria is noted in this setting.     

Intrarenal arterial Doppler sonography in the detection of renal vein thrombosis of the native kidney

OBJECTIVE: Previous studies of transplant kidneys and recent reports on native kidneys have suggested intrarenal arterial Doppler findings can be helpful in the noninvasive workup of renal vein thrombosis. We used arterial Doppler sonography to evaluate cases of possible acute renal vein thrombosis in native kidneys that had equivocal results on standard Doppler analysis of the renal vein. MATERIALS AND METHODS: Twenty native kidneys in 12 patients with clinical findings suggestive of acute renal vein thrombosis had Doppler studies of the main renal vein that failed to show normal flow. In all 20 kidneys, duplex Doppler study of arcuate/interlobar intrarenal arteries was done and the resistive index was determined. The Doppler findings were compared with subsequent findings on either renal venograms (n = 11) or MR images (n = 9), which served as the reference "gold" standards. RESULTS: The prevalence of renal vein thrombosis was 25% (5/20). Ten kidneys had very abnormal findings on arterial Doppler studies (absent or reversed end-diastolic flow), but only two of these were proved to have renal vein thrombosis. In six other kidneys, end-diastolic flow was identified but the resistive index was still elevated (> or = 0.70), and only one of these kidneys was proved to have renal vein thrombosis. Four kidneys had normal arterial Doppler studies, and 50% (two) of these were proved to have renal vein thrombosis. When absent or reversed end-diastolic flow was used as a sign of renal vein thrombosis, intrarenal arterial Doppler analysis had a sensitivity of 40% (2/5) and a specificity of 47% (7/15). CONCLUSION: Unlike the reported experience in transplanted kidneys, intrarenal arterial Doppler analysis is neither sensitive nor specific for renal vein thrombosis in native kidneys. An intrarenal arterial Doppler study with normal findings should not prevent further workup if Doppler findings in the renal vein are equivocal, nor should absent or reversed end-diastolic arterial signals be considered highly suggestive of renal vein thrombosis.     

Clinical experience with temporary vena caval filters

PURPOSE: To look at the benefits and complications of different vena caval filters inserted prophylactically. Three temporarily implantable caval filter systems were used in 67 patients. MATERIALS AND METHODS: Twelve Cook filters (six transjugular, six transfemoral), 11 Angiocor filters (one transjugular, 10 transbrachial), and 44 Antheor filters (three transjugular, four transfemoral, 37 transbrachial) were successfully implanted. In known iliac vein or caval thrombosis, the prophylactic filters were placed during thrombolytic therapy in 46 cases, surgery in 17 cases, thrombosis in pregnancy in three cases, and high-dose heparinization without lysis in one case. RESULTS: One patient had a fatal pulmonary embolism during treatment; seven thrombi were detected in the filter. Other complications were caused either by the underlying therapy alone (one fatal outcome of abdominal aorta aneurysmal surgery, two cases of cerebral hemorrhage, two cases of retroperitoneal hematomas, two cases of streptokinase fever reactions, one compartment syndrome, two cases of macrohematuria), by the combination of therapy and caval filter implantation (three cases of groin hematomas, three cases of arm hematomas), or by filter implantation alone (two cases of subclavian vein thrombosis, one catheter infection, one dislocation, one air embolism, one basket rupture). The bleeding complications were related to the aggressive thrombolytic therapy and would have occurred without filter implantation. CONCLUSION: Because temporary caval filters have no long-term complications per se, their use seems sensible as long as there are stringent indications, including the presence of iliac vein or caval thrombosis and risk of thrombus mobilization. The Antheor filter system was the most convenient system for implantation.     

In vitro activity of polyunsaturated fatty acids on Pseudomonas aeruginosa: relationship to lipid peroxidation

The treatment of patients with deep vein thrombosis and pulmonary embolism with contraindications for a thrombolytic therapy is a therapeutic challenge. We report on a 12 year old patient who was treated for large cell lymphoma according to NHL-BFM 95: Block AA protocol. During his therapy, he developed a thrombosis of his right femoral vein and pulmonary embolism affecting the left segments 4, 5, 8, and 9. Because of cerebral metastasis a fibrinolytic therapy was contraindicated. Therefore, we performed a mechanical thrombectomy using the Amplatz thrombectomy device. The postinterventional scintigraphy showed a markedly improved pulmonary perfusion; dopplersonography 4 months postinterventionally showed a patent right femoral vein.     

Interventional radiology in the treatment of pulmonary embolism

Percutaneous therapy of pulmonary embolism is performed by local administration of thrombolytic agents or by mechanical canalization. The latter is achieved by fragmentation of the embolus with angiographic catheters, or by aspiration or fragmentation of the thrombus with dedicated devices. The pharmacologic basis of locoregional administration of thrombolytic agents, as in the treatment of deep vein thrombosis, is the possibility of reaching a higher concentration of the drug at the level of the embolus by decreasing the activity of systemic fibrinolysis, thus lowering the incidence of hemorrhagic complications. In recent years, locoregional thrombolytic therapy has been used only combined with mechanical canalization. The easiest way is direct fragmentation of the embolus with an angiographic catheter. The system of aspiration of pulmonary emboli, experimented by Greenfield is based on the use of a flexible catheter the tip of which is equipped with a plastic radiopaque cup. Recently, several rotating devices have been designed. Some have already been used for the peripheral arterial system, others are specific for the venous system (Schmitz-Rode-Gunther device). The clinical effectiveness of these devices is however still to be assessed. Other non conventional possibilities for the mechanical canalization of pulmonary arterial system are represented by metal stents and angioplasty with balloon catheters. At present, interventional radiologic procedures represent an additional tool in the medical or surgical therapy of severe pulmonary embolism, when it is contraindicated or ineffective.     

Antimicrobial activity of 12 broad-spectrum agents tested against 270 nosocomial blood stream infection isolates caused by non-enteric gram-negative bacilli: occurrence of resistance, molecular epidemiology, and screening for metallo-enzymes

From March 1989 to March 1993, six athletic patients were treated in our institution by thrombolytic therapy for acute effort axillary-subclavian vein thrombosis in thoracic outlet syndrome. Mean age of these patients was 20 (range 14 to 27). An in situ infusion with urokinase (2,500 U/kg/h) and Heparin (100 U/kg/12 hours) was given during 64 hours (Range 14 to 72). Phlebography showed a complete reperfusion in three cases (the treatment began within an average period of 5.6 days), partial reperfusion in two cases (the treatment began within an average period of 8.5 days). In one case there was no reperfusion on phlebography: treatment began within an average period of 15 days. For this patient, a venous axillo-jugular bypass graft was performed. In all cases, there was no bleeding complication. A trans-axillary first rib resection was done three months later. Mean follow up was 31 months (range: two to 51 months). All patients recovered their previous physical status. Echo-Doppler exam showed normal subclavian vein flow in four cases, partial occlusion in one case and a total occlusion of the subclavian vein flow in one case. In this last case, the thrombolytic therapy failed to restore the permeability of the subclavian vein. Bypassgraft was patent. Axillary-subclavian vein thrombosis seen within a period of seven days should be treated by local thrombolytic therapy using urokinase and heparin.     

Mechanical thrombectomy in acute and subacute thrombosis with use of the Amplatz device: arterial and venous applications

PURPOSE: To perform a feasibility study of the Amplatz Thrombectomy Device (ATD) in a variety of vascular territories with acute or subacute thrombosis. MATERIALS AND METHODS: Thirteen patients (mean age, 44.6 years) with multiple risk factors who had acute/subacute thrombosis of the inferior vena cava (IVC) and iliac veins (n = 3), superior vena cava (SVC) and/or subclavian veins (n = 3), lower extremity polytetrafluoroethylene (PTFE) graft (n = 2), iliac artery (n = 2), portal vein and transjugular intrahepatic portosystemic shunt (TIPS) (n = 2), and an IVC to pulmonary artery Fontan conduit (n = 1), were treated by means of mechanical thrombectomy with use of the ATD. Thrombolysis failed to recanalize the vessels when used before thrombectomy for 12-34 hours in three patients, and was contraindicated in three other patients. Thrombolysis was used as a complement to the ATD procedure in five patients. RESULTS: Technical success was achieved in 11 patients, and procedure success was achieved in 10 patients. Failure was observed in the remaining three patients. One patient with a PTFE graft was successfully declotted but thrombosis occurred 2 weeks later, requiring surgery. The other patient with a PTFE graft did not improve and needed surgery to declot and treat the distal anastomosis and distal circulation. The two patients with an occluded iliac artery underwent successful declotting but rethrombosis occurred in one shortly after the procedure requiring thrombolytic therapy. One patient with TIPS thrombosis improved and another patient with a thrombosed portal vein did not improve after thrombectomy. CONCLUSION: The ATD is useful for recanalization of acute/subacute clotted native vessels and grafts. The application of the device is broad, and although declotting can be achieved in most cases, long-term success may be limited by anatomical and technical problems of the grafts and multifactorial clinical problems of severely sick patients, as was the case in the series. The use of additional thrombolytic therapy may be necessary in a number of patients.     

Renography in diagnosis and follow-up of renal vein thrombosis

The case of a patient in whom the diagnosis of renal vein thrombosis was supported by renographic and scintigraphic patterns that disappeared several days after the initiation of heparin therapy is reported. This observation suggests that renal investigation with radionuclides can be an important aid in the diagnosis and follow-up of patients with acute renal vein thrombosis.     

Refractory ascites due to portal vein thrombosis in liver cirrhosis--report of two cases

Portal vein thrombosis as a complication of liver cirrhosis has been reported to be extremely rare in Japan, as compared with European countries. There are few reports discussing the correlation of portal vein thrombosis with refractory ascites. Between January 1994 and December 1995, 20 cases (91%) of 22 patients with liver cirrhosis with ascites admitted to our hospital responded well within 2 months to a combination therapy of diuretics and albumin infusion, and the other two cases (9%) with refractory ascites were associated with portal vein thrombosis. The ascites in the first patient continued for 1 year, despite diuretics and albumin infusion therapy, and portal vein thrombosis was confirmed by autopsy. The ascites in the other patient continued for more than 4 months, and portal vein thrombosis was detected by ultrasound. Portal vein thrombosis was not found in the other 20 cirrhotic patients with ascites. These two cases suggest that portal vein thrombosis may be a contributing factor to refractory ascites in patients with decompensated liver cirrhosis.     

Renal vein thrombosis as the major cause of renal failure in familial Mediterranean fever

Eighteen out of 57 patients (31-6 per cent) suffering from Familial Mediterranean Fever (FMF) were found to have the nephrotic syndrome, histologically proven amyloidosis and progressive renal failure. In 14 cases renal function deteriorated rapidly after the first appearance of significant proteinuria, and 12 cases (66-7 per cent) required regular haemodialysis. Seven of these patients, seen in the early stages of renal impairment, were subsequently diagnosed clinically as probably having developed renal vein thrombosis. There was radiological proof of intrarenal or major renal vein occlusion in five which in one patient progressed to inferior vena cave obstruction. Treatment with heparin, plasminogen activators and fibrinogenolytic agents was disappointing although renal function has stabilized in one patient on long term oral anticoagulant therapy. It is suggested that renal vein thrombosis is common in FMF with renal amyloidosis and usually causes rapid deterioration of function and irreversible renal failure requiring dialysis. Renal phlebography may delineate clot in the main renal veins or indicate areas of reduced blood flow due to thromboses in intrarenal venules. Treatment is only partially satisfactory but there is some evidence to suggest that renal phlebography should be undertaken promptly when renal function begins to fall followed by anticoagulant therapy to prevent further thromboembolic complications.     

Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound

BACKGROUND: Two different diagnostic strategies are used to perform compression (real-time) ultrasound for the diagnosis of clinically suspected deep-vein thrombosis. One is to examine the entire proximal venous system from common femoral to distal popliteal vein; the other is a limited examination of only the common femoral and the entire popliteal vein. The latter strategy, which is less time-consuming and requires less expensive equipment, is based on a strong impression from prospective studies using limited compression ultrasound that proximal vein thrombi always involve the common femoral or popliteal vein. This impression, which is supported by the demonstrated safety at long-term follow-up of not treating patients whose limited compression ultrasound is normal at presentation and then repeated within the next week, has not been tested in a formal study. Therefore, we reviewed a large series of venograms performed in consecutive patients with clinically suspected venous thrombosis to determine the distribution of venous thrombosis in symptomatic patients. METHODS: Venograms were performed using 150 mL of radiographic contrast material. Before the study, a panel of experts agreed on the standardized criteria for the assessment of venograms. Venograms were adjudicated blindly for the presence of deep vein thrombosis and to determine the distribution of proximal vein thrombosis and isolated calf-vein thrombosis, the size of proximal thrombi, and whether they were occlusive or nonocclusive. Subsequently, the duration of symptoms was related to the venographic findings. RESULTS: Five hundred sixty-two venograms from consecutive patients with a first episode of clinically suspected deep vein thrombosis were adjudicated. Of these, 20 (3.6%) were inadequate for interpretation. In the remaining 542, venous thrombosis was demonstrated in 189 instances (prevalence, 35%; 95% confidence interval, 31% to 39%) and were located in the proximal veins in 166 (88%; 95% confidence interval, 82% to 92%) venograms. Isolated calf-vein thrombosis was present in the remaining 23 (12%; 95% confidence interval, 8% to 18%) venograms. Proximal with concurrent calf thrombosis was detected in 164 (99%) of the 166 patients. Proximal thrombi involved only the popliteal vein in 16 (10%); the popliteal and superficial femoral veins in 70 (42%); and the popliteal, superficial, and common femoral vein in eight (5%); whereas thrombi involving the entire proximal deep venous system were detected in 58 (35%) venograms. Isolated thrombosis of the superficial femoral, common femoral, and iliac vein was not observed. Proximal venous thrombi were occlusive in 146 (88%) patients. No relation between the duration of symptoms and the extent or the occlusiveness of venous thrombi could be demonstrated. CONCLUSIONS: Most symptomatic patients have extensive occlusive proximal vein thrombosis at the time of presentation. Thrombi isolated to the superficial femoral or iliac vein were not observed in this large sample of consecutive patients. Our data support the use of the relatively simple, inexpensive, and rapid compression ultrasound method that limits the examination of the proximal veins to the common femoral and popliteal veins.     

The scintigraphic pattern of acute renal vein thrombosis

The radiographic pattern of acute renal vein thrombosis is well known; however, the scintigraphic appearance has not been described. A scintigraphic pattern of delayed blood flow to a relatively large kidney and delayed blood flow to a relatively large kidney and delayed accumulation of l-131-Hippuran should be considered suggestive of acute renal vein thrombosis in the appropriate clinical setting.     

The treatment of established iliofemoral deep vein thrombosis with streptokinase

Sixteen patients (mainly Blacks) with iliofemoral deep vein thrombosis were treated with streptokinase and the results assessed by venography. Clear improvement in the venographic appearance was limited to 3 patients, but clinical improvement in the affected leg occurred in all patients. The thrombolytic effect of streptokinase cannot be assessed on clinical criteria alone. The purpose of this report is to draw attention to the poor clearing of main venous channels by streptokinase therapy.     

The role of the costo-clavicular compression syndrome within the framework of fibrinolytic therapy of deep arm-vein thrombosis

Eight patients with upper extremity deep-vein thrombosis were treated with thrombolytic agents. The role of a compression syndrome of the costo-clavicular space (found in 5 out of 7 cases) as a probably thrombogenetic factor is discussed. The complications of the therapy were considerable, despite frequent laboratory controls. In one thrombosis of more than 6 months' standing the treatment was ineffective. In the other 7 cases the early clinical results were good. At follow-up 14 to 57 months after thrombolytic therapy, 5 out of 7 cases had residual symptoms (rethrombosis in 2 cases). This may be due to the fact that the compression syndrome was not initially treated, with resultant persistence of the chronic trauma to the vein. Better results can be expected from fibrinolytic therapy in combination with surgical correction of any anatomical narrowing.     

Improved survival of en bloc renal allografts from pediatric donors

PURPOSE: We developed a technical and immunological protocol to increase survival of renal transplants from pediatric donors. MATERIALS AND METHODS: En bloc kidneys (22) were procured from donors weighing 2 to 14 kg. (1 to 60 months old) and transplanted into adult recipients. In group 1 (12 patients) sequential therapy was used for kidneys with more than 35 hours of cold storage and immediate triple therapy (cyclosporine, azathioprine and prednisone) was used for those with less than 35 hours of cold storage. In group 2 (10 patients) OKT3 induction therapy was used. Mean followup was 4.7 years. RESULTS: Mean blood pressure at 1 and 4 years was not significantly different between the groups. Mean serum creatinine was not significantly different between the groups at 1 year but it was significantly less in group 2 at 4 years (1.9 +/- 1.0 versus 1.2 +/- 0.24 mg./dl., p <0.05). At 1 year of followup the complication rate was 75% in 9 of 12 patients in group 1, including 4 infections or leaks (2 lost), 6 rejections (3 lost) and 3 cases of thrombosis or hemorrhage, and 20% (p <0.01) in group 2 (1 patient had the hemolytic uremic syndrome leading to graft loss). Graft survival was significantly greater in group 2 at all 4 years of followup (p = 0.05). CONCLUSIONS: The success of pediatric en bloc renal transplantation can be enhanced by induction therapy in healthy recipients.     

Lymphomatoid tumor infiltration of renal veins

A case of bilateral renal vein infiltration and thrombosis secondary to malignant lymphoma is presented. Although the kidney frequently is known to be involved by metastatic lymphoma, uremia is a rare terminal complication. The etiology and diagnosis of this disorder are discussed. We believe that it is important to recognize renal vein thrombosis in such patients so that treatment with radiation and/or chemotherapy may restore renal function.