Pulmonary embolism and deep venous thrombosis are individual manifestations of a single entity, venous thromboembolic disease. This study aimed to assess the feasibility of 3-dimensional gadolinium-enhanced magnetic resonance angiography used as an "one-stop shop'' imaging procedure visualizing both the pulmonary arteries and the deep lower venous system within a single investigation. The inclusion criterion was a proven or excluded venous thromboembolism. Diagnosis was based on an imaging work-up for pulmonary embolism including either perfusion lung scan or contrast-enhanced spiral computed tomography, or both, and an imaging work-up for deep venous thrombosis including either venous color-coded duplex sonography or ascending phlebography, or both. A gadolinium-enhanced "one-stop shop'' magnetic resonance angiography was performed within 24 hours of completed diagnostic imaging work-up for pulmonary embolism and deep venous thrombosis in 20 patients. Results of pulmonary magnetic resonance angiography were concordant with perfusion lung scan and/or computed tomography in 90% of patients. Magnetic resonance angiography results of the deep lower venous system were concordant with venous duplex sonography and/or phlebography in 75% of patients and seemed to be more precise in 25% of patients. The "one-stop shop'' imaging procedure using gadolinium-enhanced magnetic resonance angiography was feasible and proved to offer a reliable and rapid diagnostic approach in thromboembolic disease, sparing patients' exposure to ionizing radiation and iodinated contrast media.

This study compared the acute effects of a daily infusion (for 6 days) of 10% hydroxyethyl starch (Hes) (n =6) vs 10% dextran 40 (n=8) in claudicants. During exercise on a pedal ergometer at the maximal force, O2 extraction and lactate production of the diseased leg as well as blood pressure, heart rate, hematocrit and blood viscosity were measured. After a single infusion of 500 ml Hes lactate, production decreased by 52±22% (p<0.05), with a concomitant increase of O2 extraction and maximal exercise capacity. In contrast to dextran where no changes were observed after a single dose, Hes also increased the systolic blood pressure. After 6 days of hypervolemic hemodilution therapy, hematocrit was lowered and blood pressure increased with a comparable increase of O2 extraction and maximal exercise capacity in both groups. We conclude that the decreased lactate production with the concomitant increase of O2 extraction and maximal exercise capacity is due to the increased blood pressure.

With magnetic resonance angiography and computed tomography, congenital anomalies of the inferior vena cava are diagnosed more frequently than they used to be. Accessory renal arteries identified by magnetic resonance angiography in a patient with an anomalous inferior vena cava indicated a combination of arterial and venous abnormalities. The study was initiated to screen consecutive patients with an anomalous inferior vena cava for concomitant abdominal and pelvic arterial abnormalities, and their first-degree relatives for congenital vascular anomalies. Magnetic resonance angiography identified in 2 of 5 patients with an anomalous inferior vena cava concomitant accessory renal arteries and in 5 of 11 first-degree relatives major abdominal vascular anomalies including accessory renal arteries, accessory renal veins, and anomalies of the hepatic artery. None of the relatives showed abnormalities of the inferior vena cava. The familial occurrence of vascular anomalies strongly suggests an underlying pathogenetic component in affected family members. In patients with a congenital anomaly of the inferior vena cava, concomitant arterial abnormalities should be considered. First-degree relatives may be at risk for congenital vascular anomalies.

Hypovitaminosis D is common in patients with peripheral arterial disease (PAD). Subsequent secondary hyperparathyroidism and osteomalacia contribute to bone pain and myalgias, and so aggravate clinical symptoms of claudication. We evaluated 95 out of 297 patients with angiographically confirmed PAD stages II (pain in the calves and/or thighs only during exercise) or IV (history of, or presence of local ulcers) and compared them with 44 matched healthy controls regarding their medical history, bone density measurements of the femoral neck and calcaneal bone ultrasound. Bone pain, myalgias and mobility restriction as well as routine laboratory parameters, serum vitamin D [25(OH)D], crosslaps (CTX), parathyroid hormone (PTH), osteocalcin (OC) and alkaline phosphatase (AP) were recorded and analysed. 25(OH)D was significantly lower in PAD IV patients (9.6+/-4.6 ng/ml, P<0.0001) as compared to PAD II stages and controls (19.0+/-7.6 and 19.1+/-9.1 ng/ml), paralleled by lower serum calcium [2.24+/-0.02 mmol/l, P=0.0002 versus PAD II (2.36+/-0.02) and P<0.0001 versus controls (2.39+/-0.02)] and higher iPTH serum levels (66.3+/-3.6 pg/ml, P<0.0001) as compared to PAD II patients (45.3+/-3.5) and healthy controls (38.5+/-2.4). Alkaline phosphatase and serum crosslaps values were significantly higher and age-adjusted bone density and bone ultrasound measurements significantly lower in PAD IV patients, who were also twice as likely to have bone pain and myalgias as PAD II patients. Bone ultrasound measurements correlated significantly with both clinical severity and pain as well as serological parameters of bone metabolism. Underlying PAD has a significant impact on bone density and metabolism as well as on bone and muscular pain. Patients with PAD are at high risk for osteoporosis and osteomalacia and should be regularly monitored and treated for their vitamin D deficiencies.

Ziele: Bestimmung der Wertigkeit des blood-pool Kontrastmittels NC100150 (Amersham Health, Oslo, Norwegen) zur Evaluation von Thrombosen der tiefen Becken- und Beinvenen. Methode: Es wurden 12 Patienten prospektiv mittels konventioneller Venographie (XRV) und mittels MR Venographie (MRV) nach Injektion von NC100150 (2ml/kg KG) untersucht. Die source images und 3D maximum intensity projection images (MIP) wurden an einer unabhängigen Workstation ausgewertet. Die Diagnose wurde von 2 Radiologen im Konsens erhoben. Ergebnis: Bei 87 Venen waren sowohl die XRV als auch die MRV von diagnostischer Qualität. In der XRV wurden in 30 von 87 Venen Thromben gefunden (34,5%). Übereinstimmung in der Thrombusdiagnose lag bei 83 von 87 Venen vor (95,4%; Kappa=0,9). Im Vergleich zur XRV hatte die blood-pool MRV insgesamt eine Sensitivität und Spezifität von 93,3% und 96,5%. Zwei Thrombosen der vena poplitea und der vena tibialis posterior kamen in der MRV zur Darstellung, nicht aber in der XRV. Andererseits konnten zwei Venenthrombosen unterhalb des Kniegelenkes nicht mittels MRV dargestellt werden, wohl aber in der XRV. Schlussfolgerung: NC100150 erlaubt eine verlängerte und verbesserte Darstellung der peripheren Venen und könnte einige Einschränkungen der gadoliniumverstärkten MRV umgehen. Es ist eine vollständigere Untersuchung der proximalen Venen möglich als in der konventionellen XRV. Arterielle und venöse Kontrastierung und Bewegungsartefakte können jedoch zu Einschränkungen der Bildinterpretation führen.

The purpose of this study was to determine the value of a blood‐pool contrast media (NC100150, Nycomed Imaging (now Amersham Health) Oslo, Norway) for evaluation of venous thrombosis of the deep veins of the pelvis and lower extremities. Twelve patients were prospectively evaluated with conventional X‐ray venography (XRV) and MR venography (MRV) after injection of NC100150 (2 ml/kg body weight). The source images and 3D maximum intensity projection (MIP) were viewed on an independent workstation. Diagnosis was made in consensus from two radiologists. Diagnostic image quality was achieved in 87 veins with XRV and MRV. As determined by XRV, thrombus was present in 30 out of 87 veins (34.5%). There was agreement concerning absence or presence of thrombi in 83 out of 87 veins (95.4%; κ = 0.9 ± 0.05). Compared to XRV, overall sensitivity and specificity of blood‐pool MRV were 93.3% and 96.5%, respectively. Two venous thromboses of the popliteal and posterior tibial vein were diagnosed in MRV, but not in XRV. Conversely, two venous thromboses below the knee had been missed by MRV. NC100150 allows prolonged and improved visualization of the peripheral vasculature and may overcome some limitations of gadolinium contrast media. A more complete examination of the proximal venous tree may be possible than with conventional XRV. Arterial and venous enhancement and motion artifacts can limit image interpretation. Magn Reson Med 50:993–1002, 2003. © 2003 Wiley‐Liss, Inc.

OBJECTIVE: To investigate via the vitamin D status whether patients with peripheral arterial disease (PAD) tend to develop vitamin D deficiency that in turn influences their clinical symptoms.DESIGN: Cross-sectional.SETTING: University hospital.PATIENTS AND PARTICIPANTS: Three hundred twenty-seven patients were evaluated; subjects with secondary causes of bone disease or bone active medication were excluded. One hundred sixty-one patients with either PAD stage II (n = 84) or stage IV (n=77) were enrolled and compared to 45 age- and sex-matched healthy controls.MEASUREMENTS AND MAIN RESULTS: All patients underwent determinations of serum chemistry, 25-hydroxyvitamin D (vitamin D3) intact parathyroid hormone (iPTH), alkaline phosphatase (ALP), and osteocalcin and were further stratified according to an individual restriction score into 3 groups: mildly, moderately, or severely restricted in daily life due to the underlying disease. Patients with PAD IV showed significantly lower vitamin D3 (P=.0001), and calcium (P=.0001) values and significantly higher iPTH (P=.0001), osteocalcin (P=.0001) and ALP (P=.02) levels as compared to patients with PAD II. Patients considering themselves as severely restricted due to the underlying disease showed lower vitamin D3 and higher iPTH levels than those who described only a moderate (vitamin D3: P<.001; iPTH: P<.01) or mild (vitamin D3: P<.001; iPTH: P<.001) restriction in daily life.CONCLUSION: Patients with PAD IV, especially those who feel severely restricted due to the disease, are at high risk of developing vitamin D deficiency, secondary hyperparathyroidism, and ultimately osteomalacia due to immobilization and subsequent lack of exposure to sunlight, all of which in turn lead to further deterioration. Monitoring of vitamin D metabolism and vitamin D replacement therapy could be a simple, inexpensive approach to mitigating clinical symptoms and improving quality of life in patients with advanced PAD.

Background: Cases of deep venous thrombosis in the lower extremities triggered by abnormalities of the vena cava have been reported.Objective: To describe anomalies of the inferior vena cava in patients with deep venous thrombosis.Design: Prospective, consecutive case series.Setting: University Hospital, Graz, Austria.Patients: 97 patients with deep venous thrombosis.Intervention: Sonography, venography, or both to diagnose deep venous thrombosis; magnetic resonance angiography to image the inferior vena cava.Measurements: Anomalies of the inferior vena cava imaged by magnetic resonance angiography.Results: 31 of 97 patients showed thrombotic occlusion of iliac veins (common and external iliac vein [n = 29] or external iliac vein [n = 2]). Five of 31 patients (3 men, 2 women) had an anomaly of the inferior vena cava. Anomalies were missing inferior vena cava, hypoplastic hepatic segment, and missing renal or postrenal segments. Patients with anomalies were significantly younger than the 92 patients without (mean age +/- SD, 25 +/- 6 years vs. 53 +/- 19 years; P = 0.002). In 2 patients with anomalies, the thrombotic occlusion was recurrent.Conclusions: An anomaly of the inferior vena cava should be suspected if thrombosis involving the iliac veins is seen in patients 30 years of age or younger. Patients with both an anomaly and thrombosis may be at higher risk for thrombotic recurrence.

The aim of the study was to demonstrate an activation of polymorpho-nuclear leukocytes (PMNs) in chronic progressive atherosclerosis (ATH). A group of patients with ATH, and a group of ATH patients under aspirin (ASA) therapy were compared with control persons without atherosclerotic alterations (healthy controls). Each group comprised 15 male age-matched subjects. The following inflammatory parameters related to PMN activities were measured: the polymorphonuclear leukocyte (PMN) blood count; blood PMN migration and reactive oxygen species release in vitro; the blood levels of PMN elastase, malondialdehyde, antibodies to oxidized LDL and soluble ICAM-1. In ATH patients, the PMN blood counts and the share of blood PMNs migrating upon platelet activating factor and leukotriene B4 stimulation were significnatly above the values of the healthy controls, while the other parameters were not significantly altered. ASA treatment attenuated the inflammatory response and reduced the differences between ATH and the healthy controls. It can be concluded that, in patients with chronic progressive atherosclerosis, PMNs are involved in the inflammatory process underlying the disease.

Deep venous thrombosis (DVT) and pulmonary embolism (PE) are less common after knee arthroscopy than after elective hip and knee arthroplasties. There is no consensus on the optimal prophylaxis. In this prospective cohort study, we used ultrasound, phlebography and lung scan pre- and postoperatively to assess the incidence of thromboembolic complications in 101 consecutive patients who underwent knee arthroscopy. Preoperatively, patients were screened for typical risk factors for DVT such as age, obesity, varicose veins, contraceptive pills and nicotine abuse. All patients received a once-daily injection of 5000 IU of low molecular weight heparin, at least 12 hours prior to surgery.5 weeks after surgery, the same screening tests were repeated. In 12 of the 101 patients either DVT or PE was diagnosed. DVT occurred in 8 cases, 4 of which were silent and 4 symptomatic. The number of PEs was 9, 8 silent and 1 symptomatic. We found no correlation between DVT or PE and individual clinical risk factors, but there was a tendency towards the development of DVT and PE, with a higher number of risk factors. We found no correlation between DVT and intraoperative risk factors such as use of a tourniquet, type of anesthesia or duration of surgery. The relatively high rate of thromboembolic events after knee arthroscopy in our study suggests the need of all patients for routine use of thromboprophylaxis, probably in a higher dose than given.

Injury of the vertebral artery and the cervical parts of the internal carotid arteries represents a rarely encountered combination of injuries, which increases the likelihood of infarction and carries the risk that one of the diagnoses could be missed. This rare injury is reported in l-2 per cent of blunt injuries to the neck6r9z1’. The close anatomic relationship between vertebral arteries and cervical vertebrae makes it likely that dislocating spinal injuries may cause stenosis or occlusion of one or both of these arteries12. Frequent findings are pseudoaneurysms’4, arterial embolP or occlusion of the vertebral artery13,22. Most common causes are penetrating injuries of the neck4,14 diving;, sports injuries such as football, wrestling or chiropractic manipulatiorP and closed injuries of the head and neck 5. This paper presents a case with non-penetrating injury of the neck in a young patient, causing injury to the cervical spine and to the vertebral and carotid arteries without neurological sequelae.

Objective: To evaluate nonsurgical alternatives in reopening chronically occluded aortic bifurcation.Design: Uncontrolled randomized study.Setting: University-affiliated referral center for vascular diseases.Patients: Twenty-five of 39 consecutive patients with chronic aortoiliac disease including a totally occluded aortic bifurcation were found to be acceptable candidates for an aortobifemoral prosthetic graft.Intervention: Patients were randomly assigned to receive either streptokinase or urokinase or recombinant tissue-type plasminogen activator (rt-PA). In cases of successful thrombolysis and residual obstructions, subsequent balloon angioplasty was attempted. Prosthetic bypass grafting was done if thrombolytic treatment and balloon angioplasty failed.Results: Complete lysis was achieved in 5 of 25 patients (20%). In 10 (40%) patients, lysis showed residual obstructions, which were reopened mechanically in 8 patients; 2 patients had extra-anatomical bypass grafts. Ten patients (40%) without thrombolysis had surgical aortobifemoral bypass grafts. Overall, recanalization and clinical improvement were achieved in 13 of 25 patients (52%) by thrombolytic therapy and subsequent balloon angioplasty. The recanalization rate did not differ among the different thrombolytic drugs. However, rt-PA therapy resulted in reopening after 4 days of treatment; streptokinase, after 6 days; and urokinase, after 9 days (P < 0.005). No major complications or deaths occurred.Conclusion: Thrombolytic treatment followed by balloon angioplasty may help avoid the need for aortobifemoral prosthetic bypass grafting in more than 50% of patients with chronic aortoiliac disease.

One-hundred and fifty patients with thrombotic and 60 patients with embolic occlusions of the superficial femoral and/or popliteal artery underwent a simplified IAT (intra-arterial thrombolysis) procedure. Ten mg rt-PA combined with 3000 IU Heparin were infused over 6 h, thereafter the extent of thrombolysis was checked fluoroscopically and the above mentioned treatment course repeated up to four times if necessary. The IAT regimen employed did not involve mechanical recanalization attempts; if complete thrombolysis revealed an underlying stenosis, a PTA (percutaneous transluminal angioplasty) was subsequently performed. IAT resulted in complete recanalization of 88 thrombotic occlusions (59%; 95% confidence interval: 50.8%-66.8%) and of 53 embolic occlusions (88%; 95% confidence interval: 77.1%-94.8% P < 0.001). In a further 33 (22%) thrombotic and four (7%) embolic occlusions IAT reduced the length of the occluded segment. At discharge, 102 (67%) patients with thrombotic and 55 (92%) patients with embolic occlusions were clinically improved. Overall, untoward effects occurred in 60 patients (29%): 47 (22%) were minor. Four patients (2%) suffered a systemic haemorrhage (three gastrointestinal, one macrohaematuria). The cumulative potency rate was significantly higher in patients with embolic occlusions throughout follow-up (82% vs 49% for thrombotic occlusions at 2 years, P < 0.001). Although all amputations were carried out in patients with thrombotic occlusions, follow-up mortality did not differ significantly between patients with embolic and thrombotic occlusions.