Effects of intravenous and catheter directed thrombolytic therapy with recombinant tissue plasminogen activator [Alteplase] in non-traumatic acute limb ischemia; a randomized double-blind clinical trial

Objective: To evaluate the efficacy and safety of intravenous and catheter directed thrombolysis by recombinant tissue plasminogen activator [Alteplase] in the patients with non-traumatic acute limb ischemia [ALI]

Methods: This was a randomized clinical trial being performed between 2009 and 2011 in Mashhad University of Medical Sciences. We included those patients who were<75 years, with symptoms of less than 14 days duration, ALI of grade IIa and IIb [according to Rutherford classification] and absence of distal run off. Baseline assessment of peripheral circulation performed in all the patients. Patients were randomly assigned to undergo intravenous [n=18] or catheter directed thrombolysis [n=20] with Alteplase. The primary endpoint of the study was improvement of clinical status measured by Rutherford classification, ankle brachial index [ABI], visual analogue scale [VAS] score measured at 1, 3 and 6 months. The secondary endpoint of the study was complete or near complete recanalization of the occluded artery

Results: A total number of 38 patients with mean age of 54.13 +/- 13.5 years were included in the study. There were 23 [60.5%] men and 15 [39.5%] women among the patients. Overall 3 [7.9%] patients had upper and 35 [92.1%] lower extremity ischemia. There was no significant difference between two study groups. None of the patients experienced major therapeutic side effects. Both ABI and VAS score improved in patients who have received first dose of t-PA within 24-hourof ALI. There was no significant difference between two study groups regarding the 6-month clinical grade [p=0.088], VAS score [p=0.316] and ABI [p=0.360]. The angiographic improvement was significantly higher in CDT group [p<0.001]

Conclusion: Intravenous and catheter directed thrombolysis with t-PA is a safe and effective method in treatment of acute arteriolar ischemia of extremities. However there both intravenous thrombolysis and CDT are comparable regarding the clinical outcome

Angiographic findings of patients with blunt or penetrating extremity injuries: focus on indications and contraindications

Objective: To determine the etiology, signs and symptoms, angiography indications and angiography findings in patients with limb penetrating injuries suspected to have arterial injury

Methods: This was a cross-sectional study being performed in Imam Reza Hospital affiliated with Mashhad University of Medical Sciences, Iran between September 2011 and March 2013. We included those patients with extremity blunt and penetrating injuries who were referred for angiography according to standard indications including abnormal distal pulses, complex fracture or dislocation, vascular proximity, fixed hematoma, distal nerve deficit, arterial bruit, thrill and massive soft tissue injuries

Results: During the study period, 148 patients [15 women and 133 men] with a mean age of 31+/-14.9 [11-82] years were evaluated. The most common cause of injury was motor vehicle accident [127 patients 85%]. Angiography indications included abnormal distal pulse examination [124, 83.8%], complex fracture or dislocation [7, 4.7%], near arterial trauma [4, 2.7%], fixed hematoma [3, 2%], nerve damage [1, 0.7%]. The angiography was found to be normal in 49 [33.1%] patients. In patients with abnormal angiography findings, 60 [60.6%] had cutoff with distal runoff, 21 [21.2%] had cutoff without runoff, 14 [14.1%] had arterial spasm. Other uncommon findings included active bleeding in 2 patients [2%], pseudoaneurysm in 1 [0.7%] and arteriovenous fistula in 1 [0.7%]. Out of 4 patients [2.7%] with vascular proximity, only 1 [0.7%] had abnormal angiography

Conclusion: The most important factor in prediction of result of angiography was distal arterial pulses examination. But these data confirm the low incidence of vascular injury in asymptomatic patients with proximity. So the use of angiography when proximity is the sole indication in an asymptomatic patient with a normal vascular examination should be questioned

Comparison of conventional angiographic findings between trauma patients with or without runoff

Objective: To compare the conventional angiographic findings in extremity trauma patients with or without runoff

Methods: This was cross-sectional study including all the patients with extremity trauma who underwent conventional angiography during the 2 year period from 2011 to 2013 in Angiography departments of Mashhad University of Medical Sciences. Mechanism of trauma, type of injury and angiographic findings were recorded in a questionnaire for each patient. After completion of treatment and discharge, the treatment type was added. The characteristics as well as clinical findings were compared between those who were diagnosed to have arterial runoff ad those who did not

Results: One hundred and forty eight traumatic patients including 15 female with age range of 11-82 years and 133 men ranging from 25 to 40 years were enrolled. Abnormal angiographic findings were provided in 99 [66.9%] patients including cutoff with distal runoff [n=60, 60.6% of abnormalities], cut off without distal runoff [n=21, 21.2%] and spasm [n=14, 14.1%] and other findings [n=4, 4%]. Fifty one cases were treated under open surgery and amputation of traumatic limb was done for 13 patients. Amputation rate was higher in patients with cutoff and without runoff than those with cutoff and runoff [33.3% vs. 6.78%; p=0.002]

Conclusion: Causes and types of traumatic arterial injury in our study were different with other reports. It was shown that angiographic findings were less important in prognosis and management of patients. Patients with spasm in angiographic findings had a better prognosis than other patients and mostly did not need any vascular surgery. The presence or absence of a distal run off in primary angiographic findings can have a predictive value in the final amputation rate

Subciliary approach for inferior orbital rim fractures; case series and literature review

Objectives: To report the outcome of subciliary approach for inferior orbital rim fractures in a series of Iranian Patients

Methods: This was prospective cross-sectional, being performed during a 12-month period during 2013 in plastic surgery department of Emamreza Hospital of Mashhad. We included 12 patients with traumatic inferior orbital rim fractures who underwent surgical repair through subciliary approach. All the patients were followed for 12 months and were evaluated regarding paresthesia and function as well as presence of a visible scar and lower-eyelid malposition

Results: There were 9 [75.0%] men and 3 [25.0%] women among the patients with mean age of 26.3 +/- 10.6 [range 16-48] years. Of the 12 patients treated with the subciliary approach, 4 [33.3%] experienced complications. One [8.3%] patient showed 1.5 mm sclera at the end of one year follow-up. No ectropion or entropion was reported in our series. In contrast to 3 [25.0%] cases of lower lid visible scar, there was no occurrence of hypertrophic scar

Conclusion: It would be expected that the transorbital approach as it offers good visualization of anterior fractures would result in good outcomes in cases of orbital rim and floor fracture

Knowledge of iranian medical interns regarding cardio-pulmonary resuscitation

Cardio-Pulmonary Resuscitation [CPR] is one of the most important procedures in emergency medicine. As new trends are evolving in medical education, we planned to evaluate the interests and knowledge of medical students regarding educational methods in CPR learning. In a cross-sectional analytical descriptive study, a standardized questionnaire was distributed among 180 medical interns at the Mashhad University of Medical Sciences. The questionnaire had three parts: demographics, general questions, and CPR knowledge. If they had more than 10 correct answers [out of 15] in knowledge, they were placed in group A and if more than 5, in group B and correct answers less than 5 were categorized in group C. 159 interns filled the questionnaires. Mean age was 24.99 +/- 0.96 and 56.5% were female; 52.7% were educated only theoretically and 47.3% had combined theoretical and clinical knowledge; male interns were significantly more educated [P=0.041]. Residents were the majority of trainers [56.8%] and only 14.3% were educated by the staffs. Only 7% mentioned that they felt they could do a complete CPR and 37.3% considered themselves as assistants; 93.7% believed that isolated emergency ward and teaching courses were needed for better education and 95% declared that continuous education is obligatory; 33.5% were in group A and 45.8% were in group B. CPR education is of interest to most interns. Due to lack of emergency medicine wards and, the interns' knowledge and their practical skills were insufficient to perform acceptable CPR

Evaluation of patency rate for arteriovenous fistulas using superficial basilic vein transposition in dialyzing end stage renal disease patients

Long term vascular access has become more important as patients live longer on dialysis. Improved survival on hemodialysis has resulted in an increasing number of patients with failed vascular access, so an increasing number of options for vascular access have to be added to the surgeon's armamentarium. In a number of patients, basilic vein transposition is an often overlooked means of arteriovenous access that has a superior patency compared with bridge fistulas using polytetrafluoroethylene [PTFE]. And this brought vascular surgeons of Imam-Reza hospital to use this technique in patients with complications in normal fistulas. This article evaluates the survival rate of these fistulas and compares them with patency rates reported worldwide. This study was conducted on, 25 End Stage Renal Disease [ESRD] patients, undergone superficial basilic vein transposition from 2002 till 2005. In these patients, superficial basilic vein transposition method was performed for an arteriovenous fistula [AVF]. Demographic data were collected using medical records, and then patients were examined clinically. Patency rate was evaluated using life tables by SPSS version 13 and compared with similar results reported worldwide. Overall 70.8% were male patients and 29.2% were female. Hypertension was seen in 87.5% of cases and 37.5% suffered from diabetes. Seventy four percent of our cases underwent basilic vein transposition after a failing AVF, one case after a rejected transplant and one after a failed graft. The longest patency rate was 30 months and the shortest was 4 months. The patency rate for the first 6 months was 86% and after one year 77% and after 26 months 58%. The one year patency rate reported for fistulas by basilica vein transposition method is 90-60% which justifies the results of this article [62.5%]. these results suggest that this method can be used as a new access line for dialyzing ESRD patients before using graft fistulas