: Plaster cast immobilisation following trauma is a major risk factor for the development of deep vein thrombosis. In our controlled, randomized and prospective study on patients with minor injuries incidence of DVT in conservatively treated out-patients with plaster cast immobilisation of the leg was 3.9% in the control group (n = 126) without prophylaxis. By s.c. self-application of LMV heparin once daily the number of DVT in the prophylaxis group (n = 115) was reduced to 0. No severe side effects of NMH were observed. We conclude that thromboprophylaxis with LMW heparin once daily up to now conspiciously reduced the risk of DVT in outpatients with plaster cast immobilisation of the leg.
The release of tissue-type plasminogen activator (t-PA) after venous occlusion was tested in 290 patients with venous thrombosis, at earliest three months after the last thrombo-embolic episode. In 37 patients (12.8%) the t-PA-activity was decreased. In 14 patients (4.8%) the defect was confirmed by control. A reduced release of t-PA was found in 4 patients, while 10 out of 14 patients had comparatively higher levels of plasminogen-activator-inhibitor (PAI-I).
With lysis-block technique an over-systolic tourniquet is put on the thigh or upper arm. The fibrinolytic substance is injected into a dorsal foot vein or forearm vein. By using this strictly local lysis it was possible to remove distal venous and arterial occlusions. During over-systolic blockade there was only a minimal link between the blocked part of the limb and systemic circulation. By choosing a lytic substance with a short half-life-period (rt-PA) the systemic effect after loosening the blockade was small. LBT is a new and interesting method for the fibrinolytic treatment of peripheral venous and arterial occlusions. The procedure is characterized by minimal systemic reactions and it can probably be applied in those patients with contraindications for systemic lysis.
In a retrospective study, the data of 218 patients (age 65-91) with obstructions of leg-arteries were evaluated, who underwent short-term ultrahigh fibrinolytic treatment. Some of the patients were also treated with percutaneous transluminal angioplasty after fibrinolysis. The overall patency-rate was 69 percent in the younger age group (65-74 years) and 46 percent in the group aged > or = 75. It could be shown, however, that the patency-rate was affected positively by concomitant factors (especially at least two patent calf arteries). These factors were less frequently found in the older age group, resulting in a lower patency-rate. Most likely the underlying reason is not age per se, because it could be shown, that the reason, which led to fibrinolytic treatment changed with age: In the younger age-group, Fontaine-stage II led to treatment in the vast majority of cases (71%). There was a shift to stage III (26%) and IV (27%) in the group > or = 75 years. This progression of artery disease usually leads to a reduced success rate of fibrinolytic treatment, because adverse concomitant factors prevail.
The results of a modified UHSK lysis in patients with PAOD are presented. UHSK was most successful in the treatment of stenoses of the abdominal aorta and iliac stenoses/occlusions. After occlusions of bypasses and after angioplasty UHSK was less successful. The results after 4 and 6 hours of UHSK treatment were almost the same.
Plaster cast immobilisation following trauma is a major risk factor for the development of deep vein thrombosis. In our controlled, randomized and prospective study on patients with minor injuries incidence of DVT in conservatively treated out-patients with plaster cast immobilisation of the leg was 3.9% in the control group (n = 126) without prophylaxis. By s.c. self-application of LMV heparin once daily the number of DVT in the prophylaxis group (n = 115) was reduced to 0. No severe side effects of NMH were observed. We conclude that thromboprophylaxis with LMW heparin once daily up to now conspiciously reduced the risk of DVT in outpatients with plaster cast immobilisation of the leg.
In Raynaud's phenomenon few new medical treatment options have become available in recent years, but the merits and demerits of drugs already longer available have been established more firmly. Calcium antagonists remain the treatment of first choice even despite their frequent side effects. Prostacyclin analogues are effective but oral formulations are still eagerly awaited. In PAOD attention is shifting from the often disappointing medical treatment of symptoms to possible secondary prevention. Except for the effects of some prostanoids little clinical benefit is obtained from vasodilators and rheologically active drugs. Attempts to influence skeletal muscle metabolism with carnitine-analogues like 1-carnitine are interesting but clinical benefit has not yet been proven. In the next few years results of trials with lipid-lowering drugs to stop progression of atherosclerotic lesions will become available.
A calf ergometer is presented that can be used for both static and dynamic exercise in supine, sitting or standing position. During exercise each foot is fixed firmly to a pedal. During dynamic exercise the foot pedal can rotate through an angle which can be varied from 5 to 30 degrees. External work is performed only during plantar flexion. The amount of work is determined by the moment imposed to the pedal by a constant force spring and can be calculated from electrical signals that represent the angle of rotation and the moment exerted to the pedal. During static exercise the foot pedal is secured so that it cannot move.
Rheological tests were performed in four rigorously defined groups of patients with Raynaud's phenomenon: primary family-related (n = 21), primary family-unrelated (n = 30), 'possible scleroderma' (n = 26), and scleroderma (n = 19). Whole blood and plasma viscosity, and hematocrit were significantly higher in the 'possible scleroderma' group. We conclude that the contribution of central rheological abnormalities in the pathogenesis of Raynaud's phenomenon is limited.
An estimation of the peripheral resistance was performed during 264 peripheral bypasses. After completion of the distal anastomosis, saline was infused via the proximal graft end in constant flow rates. The mean distal pressure was used for calculation of peripheral resistance. There was a close correlation between the peripheral resistance (based on flow rates of 100 ml/min) and the 30 day graft failure rates. Below the level of 450 mPRU the failure rate was 4%, above 750 mPRU, however, this rate was more than 20%. It is concluded, that the estimation of the peripheral vascular resistance during the operation is a valuable tool to estimate the prognosis of graft patency.
Peripheral outflow resistance (OR) was assessed intraoperatively in 75 infrainguinal bypass procedures to the below knee popliteal artery (20) or a single crural artery (55). OR measurement was done after completion of the distal anastomosis. For that purpose, the graft was perfused with Ringer solution at constant flow rates of 100 and 150 ml/min using a roller pump. During infusion, arterial pressure was recorded. In this way distal (DOR) and total (TOR) outflow resistance in E/S anastomoses was calculated before and after vasodilatation with papaverine. DOR at a flow rate of 100 ml/min was found to be most discriminant as a predictor of early graft thrombosis: 1. In the limbs with a thrombosed graft at 30 days OR was significantly higher than in the limbs with a patent graft (1828 +/- 418 vs. 1472 +/- 221 mPRU; p less than 0.01, Mann-Whitney U-Test). 2. The cut-off value of 1700 mPRU, which was determined by ROC curves, was 100% sensitive and 81% specific in the group of femoro-crural grafts to predict early graft failure. A better discrimination by the application of papaverine could not be achieved. We concluded from our results that OR might be an important factor in early graft thrombosis. But still there is more experience required to select patients for primary amputation or adjunctive procedures (av-fistula, sequential graft) on the basis of the present available data.
Raynaud's phenomenon (RP) is seen in 5-10% of the population and generally follows an indolent course. In some cases it may be the first sign of a connective tissue disease (CTD). In patients referred to the clinician because of their RP, obviously the more severe cases, CTD, in particular scleroderma, will develop, however, in a considerable percentage. Risk factors for the evolution of CTD are (a) the severity of RP at onset, (b) a positive test for antinuclear antibodies, (c) nailfold capillary abnormalities, and (d) older age at onset. Patients with RP who are at risk for the development of CTD should be followed in order to diagnose (and treat) a developing CTD as early as possible.
Radioresistometry, a combination of intra-operative angiography with measurement of peripheral resistance permits a simultaneous morphological and functional judgement of the terminal flow passages. The authors describe a self constructed apparatus making possible to introduce the method into the clinical program of surgical treatment of chronic peripheral arterial occlusions. In a prospective, clinical-experimental study of 106 femoro-popliteal reconstructions they prove: 1. The method completes the preoperative angiogram, enables a more exact indication for vascular reconstruction and allows the detection of surgical technical faults. 2. In extreme values of peripheral resistance (greater than 2,5 PRU) there is no indication for arterial reconstruction in the proximal segments.
