Effect of local papaverine on arteriovenous fistula maturation in patients with end-stage renal disease / Efeito da papaverina local na maturação de fístulas arteriovenosas em pacientes com doença renal terminal

Abstract Background: Arteriovenous fistula (AVF) maturation is one of the main concerns in patients with end-stage renal disease (ESRD) and finding a strategy for increasing success rate and accelerating fistula maturation is valuable. The aim of this study was to evaluate the effects of papaverine injection on AVF maturation and success rate. Method: This study was a randomized clinical trial that involved 110 patients with ESRD that were referred for AVF construction. Patients were allocated in papaverine group and control group with block randomization according to age and sex. In the case group, papaverine (0.1 or 0.2 cc) was injected locally within the subadventitia of artery and vein after proximal and distal control during AVF construction and in the control group, AVF construction was done routinely without papaverine injection. Results: Maturation time in case and control groups was 37.94 ± 11.49 and 44.23 ± 9.57 days, respectively (p=0.004). Hematoma was not seen in the case group but occurred in one patient in the control group. One patient of the case group developed venous hypertension. Four functional fistulas, 1 (1.8%) in the case group and 3 (5.5%) in the control group, failed to mature (p=0.618). Maturation rate did not differ between the two groups statistically (p=0.101). Conclusion: Local papaverine injection increased vessel diameter and blood flow, increasing shearing stress in both arterial and venous segment of recently created AVF. In this way, papaverine probably can decrease AVF maturation time without an increase in complications.

Resumo Introdução: A maturação da fístula arteriovenosa (FAV) é uma das principais preocupações em pacientes com doença renal terminal (DRT). Assim, é importante identificar estratégias para aumentar as taxas de sucesso e acelerar a maturação da fístula. O objetivo do presente estudo foi avaliar os efeitos da infiltração de papaverina sobre a maturação da FAV e suas taxas de sucesso. Método: O presente ensaio clínico randomizado incluiu 110 pacientes com DRT encaminhados para colocação de FAV. Os pacientes foram randomizados em bloco em função de idade e sexo e alocados nos grupos caso ou controle. Os indivíduos no grupo caso receberam infiltração local de papaverina (0,1 ou 0,2 ml) no plano da sub-adventícia da artéria e veia após o controle proximal e distal durante a construção da FAV. No grupo controle, a construção da FAV foi realizada rotineiramente sem infiltração de papaverina. Resultados: Os tempos de maturação dos grupos caso e controle foram 37,94 ± 11,49 e 44,23 ± 9,57 dias, respectivamente (p = 0,004). Foi observado hematoma em apenas um paciente do grupo controle. Um paciente do grupo caso desenvolveu hipertensão venosa. Quatro fístulas funcionais, uma (1,8%) no grupo caso e três (5,5%) no grupo controle, não amadureceram (p = 0,618). A taxa de maturação não diferiu estatisticamente entre os dois grupos (p = 0,101). Conclusão: A infiltração local de papaverina aumentou o diâmetro do vaso e o fluxo sanguíneo, elevando a tensão de cisalhamento nos segmentos arterial e venoso da FAV recentemente criada. Desta forma, a papaverina provavelmente consegue reduzir o tempo de maturação da FAV sem aumentar as complicações.

Vasodilatory efficacy and impact of papaverine on endothelium in radial artery predilatation for cabg surgery: in search for optimal concentration

Abstract Objective: The aim of this study was to compare the efficacy of two different papaverine concentrations (0.5 mg/ml and 2 mg/ml) for vasospasm prevention and their impact on endothelium integrity. Methods: We have studied distal segments of radial arteries obtained by no-touch technique from coronary artery bypass graft (CABG) patients (n=10). The vasodilatory effect of papaverine (concentrations of 0.5 mg/ml and 2 mg/ml) was assessed in vitro, in isometric tension studies using ex vivo myography (organ bath technique) and arterial rings precontracted with potassium chloride (KCl) and phenylephrine. The impact of papaverine on endothelial integrity was studied by measurement of the percentage of vessel's circumference revealing CD34 endothelial marker. Results: 2 mg/ml papaverine concentration showed stronger vasodilatatory effect than 0.5 mg/ml, but it caused significantly higher endothelial damage. Response to KCl was 7.35±3.33 mN for vessels protected with papaverine 0.5 mg/ml and 2.66±1.96 mN when papaverine in concentration of 2 mg/ml was used. The histological examination revealed a significant difference in the presence of undamaged endothelium between vessels incubated in papaverine 0.5 mg/ml (72.86±9.3%) and 2 mg/ml (50.23±13.42%), P=0.002. Conclusion: Papaverine 2 mg/ml caused the higher endothelial damage. Concentration of 0.5 mg/ml caused better preservation of the endothelial lining.

Comparison of efficacy of oral drotaverine plus mefenamic acid with paracervical block and with intravenous sedation for pain relief during hysteroscopy and endometrial biopsy.

Background : Office hysteroscopy with endometrial biopsy is usually the first investigation for abnormal uterine bleeding and other uterine diseases. Aims: To evaluate the effect of oral drotaverine with mefenamic acid on pain perception during hysteroscopy and endometrial biopsy and to compare it with that of paracervical block using 1% lignocaine and with that of intravenous sedation using diazepam with pentazocine. Settings and Design : Outpatient gynecological department and open randomized trial. Materials and Methods : One hundred twenty women undergoing hysteroscopy and endometrial biopsy were randomized into 3 groups. Group I received tablet containing drotaverine hydrochloride (80 mg) + mefenamic acid (250 mg), group II received lignocaine paracervically and group III received intravenous diazepam. The intensity of pain during the procedure, 30 and 60 minutes later on visual analog scale (VAS) was assessed. Statistical Analysis : Statistical analysis was performed using Kruskal-Wallis test, with the Bonferroni correction, the t test, and the χ2 test. Results: Groups were similar in age, parity, vaginal birth or relevant medical history. A statistically significant difference in pain scores was noted among the 3 groups during the procedure (group I, 4.13± 1.28; group II, 5.93± 1.26; group III, 5.58± 1.51), (P< 0.001); as well as 30 minutes later (group I, 1.78± 0.89; group II, 2.53± 0.81; group III, 2.23± 0.94), (P< 0.001) and 60 minutes later (group I, 1.2± 0.46; group II, 1.98± 0.83; group III, 1.68± 0.75), (P< 0.001). VAS at different time intervals among the groups was also statistically significant. No adverse effects were observed. Conclusions : Oral drotaverine with mefenamic acid is effective in women undergoing hysteroscopy and endometrial biopsy.

Evaluating erectile dysfunction: oral sildenafil versus intracavernosal injection of papaverine.

BACKGROUND: Intracavernosal injection of vasoactive drugs is an established method of evaluating erectile dysfunction. However, it is invasive and may be associated with pain and priapism. We investigated the use of oral sildenafil as a possible substitute for intracavernosal agents. METHODS: Men with erectile dysfunction were randomized into two groups of 25 each. One group of 25 men received injection papaverine initially followed by oral sildenafil, and another 25 received oral sildenafil followed by injection papaverine. Genital self-stimulation was used in both the groups. Penile length and circumference as well as angle of erection, before and after each medication, were recorded. Two days later, the intervention arms were crossed over. Subjective responses were obtained. The effect of medication on each outcome variable was studied by using analysis of variance models in relation to patient, period and medication. RESULTS: There was statistically significant improvement from the baseline value in both the arms, i.e injection papaverine and oral sildenafil (p<0.001, p<0.001, respectively) for both penile length and circumference. No significant difference was observed between the two medications in the outcome measures. CONCLCUSION: Oral sildenafil was as effective as injection papaverine in evaluating erectile dysfunction.

Fisiología coronaria y su utilidad para el cardiólogo intervencionista: Medición invasiva de la presión y flujo coronarios / Coronary physiology and its usefulness for the interventionist cardiologist: Invasive measurement of coronary flow-pressure

Una de las más importantes limitaciones de la angiografía coronaria es su incapacidad para determinar el impacto fisiológico de las estenosis coronarias moderadas. La medición de la presión y del flujo sanguíneo coronario nos brinda información valiosa que complementa la evaluación anatómica y facilitan la toma de decisiones en el laboratorio de cateterismo cardíaco. En esta revisión se discuten los conceptos fundamentales de la fisiología coronaria, así como la metodología y aplicación clínica de las técnicas de medición de presión y flujo coronarios.

One of the most important limitations of coronary angiography is the inability to characterize the physiological significance of an intermediate coronary stenosis. Measuring coronary blood flow and pressure provides unique information that complements anatomic evaluation and facilitates decision-making in the cardiac catheterization unit. This review discusses the fundamental concepts of coronary physiology, methodology, and clinical applications of coronary and flow measurements.

Intracavernosal papaverine injection test for the diagnosis of erectile dysfunction, experience in 1180 patients

To evaluate the intracavernosal papaverine injection test as diagnostic tool for patients having erectile dysfunction. 1180 patients suffering erectile dysfunction were classified according to the etiology based on history and clinical assessment into three groups. Group [A], included 324 cases having primary psychogenic impotence, Group [B] included 676 patients having impotence with associated risk factors and Group [C] included 180 patients having secondary impotence without obvious cause. A bolus dose of 30 mg papaverine was injected intracorporealy in all studied patients. Color Doppler sonography was done for patients having negative papaverine test to confirm the diagnosis. Papaverine intracavernosal injection test was positive in 82% [266 cases] of Group A, 37% [250 cases] of Group B and 59% [106 cases] of Group C. Priapism was developed in 5% [18 cases], 5.3% [36 cases] and 4.5% [8 cases] of Groups A, B, and C, respectively. Negative papaverine test is valuable in impotent patients having associated risk factors [Group B], as it was negative in 63% [426 cases] of them. Color doppler sonography confirmed the diagnosis in 86% [369 cases] of them as they having arteriogenic, venogenic or mixed vasculogenic impotence. In-Group C, it was negative in 41% [74 cases] and the color Doppler sonography confirmed the diagnosis of vasculogenic impotence in 60.5% [45 cases]. In-Group A, negative papaverin test was found in 18%, [58 cases], while color doppler sonography was normal in 95% [55 cases] of them and venous leakage was found in only 5% [3 cases]. Intracorporeal papaverine injection is a good positive test to rule out major arterial insufficiency or veno-occlusive dysfunction. However, a negative papaverine test is valuable in patients having associated risk factors or those without obvious cause for their impotence. But not in patients having psychogenic impotence

effect of intra-arterial papa verine and/or angioplasty on the cerebral veins in patients with vasospasm following subarachnoid hemorrhage due to ruptured intracranial aneurysms

This study was performed in an attempt to determine if there is a change in intracranial venous diameters following carotid distribution endovascular treatment of vasospasm due to subarachnoid hemorrhage. The venous diameters were measured in all patients who received intra-arterial papaverine and/or balloon angioplasty for treatment of vasospasm from April 1993 to September 1996. The mean measured venous diameters increased significantly following papaverine [10.9%] and following papaverine and angioplasty [4.2%]. There was no statistically significant increase in mean venous diameters following angioplasty alone. Endovascular treatment produces measurable increases in intra-cranial venous diameters. However, these changes do not correlate with changes in ICP

Isquemia intestinal por bajo flujo esplácnico / Low flow splachnic intestinal ischemia

El déficit circulatorio de este cuadro se ubica en la microcirculación intestinal por fallo de bomba, shock o uso de digital. Dolor abdominal repentino, distensión, enterorragia y los antecedentes llevan a la sospecha clínica y al diagnóstico. El tratamiento es en principio médico, con el esquema de Boley (Tolazolina y Papaverina), controlado por arteriografía; si no cede, el intestino necrótico debe ser removido quirúrgicamente. Material y Método: Se consideran 22 casos. Todos consultaron por dolor abdominal repentino, distensión y enterorragia. Sólo 3 carecían de antecedentes, los 19 restantes provenían de UTI, U.C., o tenían tratamiento con digital. Se utilizó el análisis univariable de variables cualitativas. Resultados: Se operaron 18 (81,8 por ciento), falleciendo sin operar 4 (18 por ciento). La mortalidad global fue de 15 (68,1 por ciento). Siete (31,8 por ciento) tuvieron buena evolución, ellos presentaron sólo lesiones de intestino delgado.

Evaluación del paciente impotente: experiencia con papaverina intracavernosa en el policlínico de urología del Hospital San Juan de Dios / Evaluation of the impotent patient: experience with intracavernous paraverine at the urology polyclinic of the San Juan de Dios Hospital

Se presenta una casuística de 54 pacientes con impotencia por disfunción eréctil estudiados en el policlínico de urología del Hospital San Juan de Dios. En ellos destacan algunas patologías concomitantes tales como diabetes (48 por ciento) e hipertensión arterial (24 por ciento) y factores asociados eventualmente relacionados con la impotencia tales como consumo de ciertos medicamentos (30 por ciento); alcoholismo (16 por ciento) y tabaquismo (16 por ciento). El 73 por ciento de los pacientes respondieron a la administración de papaverina, lo que sugiere la participación de factores psicogénicos asociados a alteraciones vasculares leves o moderadas. Pese a los buenos resultados observados sólo el 34 por ciento de los respondedores aceptaron continuar con autoinyecciones de papaverina

Corporeal blood gas changes according to duration of drug-induced prolonged erection

The corporeal blood gas changes in accordance with the duration of the prolonged erection which developed after intracorporeal pharmacotherapy with papaverine and phentolamine were investigated in 62 impotence patients. The picture of the corporeal blood taken from 15 psychogenic impotence patients (a control group) at 10 minutes after intracavernous injection when they showed full erections was arterial but there was pCO2 rise and pH drop compared to femoral artery blood taken simultaneously. As the erection lasted longer, significant gas changes of the cavernous blood began to appear (p<0.0001): increase in pCO2 and decrease in pO2 from 4 hours, decrease in pH from 5 hours, decrease in O2 saturation from 6 hours. Erections lasting for more than 16 hours showed significantly worse hypoxia (p<0.05). Therefore, to prevent hypoxia and metabolic acidosis, drug-induced prolonged erection would be better decompressed before it lasts for more than 4 hours.

Evaluación del paciente impotente: experiencia con papaverina intracavernosa (IC) / Evaluation of the impotent patients: experience with intracavernous papaverine

Se presenta nuestra experiencia inicial con un protocolo de Papaverina I.C., efectuado en 70 pacientes impotentes, que clasificados según su respuesta a la papaverina son manejados con diferentes alternativas de terapia o estudio. El 54% de los pacientes, recuperó erecciones espontáneas. El 20% de la serie, logra erecciones con papaverina I.C., y puede beneficiarse con programa de auto inyección. El 26% restante (No Respondedores), fue sometido a evaluación arterial y venosa. Se consignó "escape venoso" en el 33% de los pacientes que complementaron este estudio, y de 4 enfermos sometidos a Cirugía uno recupera erecciones espontáneas

Tratamiento de la impotencia mediante autoinyección de papaverina intracavernosa / Impotence treatment by autoinyection of intracavernous papaverine

Se presenta una serie de 21 pacientes: 20 impotencias orgánicas (parapléjicos o fracturas de pelvis) y 1 disfunción psicogénica, tratados con inyección intracavernosa de papaverina en dosis crecientes desde 10 mg. Observan erecciones útiles en 19 enfermos y la autoinyección se denomina en promedio desde la 5a inyección. Fueron complicaciones: 5 hematomas, 3 ortostatismos, 2 dolor y 1 priapismo