Long-term outcome of successful percutaneous transluminal angioplasty of the fibular artery in diabetic foot syndrome and single-vessel calf perfusion depends on doppler wave pattern at the forefoot.

BACKGROUND: In the diabetic foot syndrome (DFS) due to peripheral artery disease, the fibular artery is often the only vessel which can be revascularised. Because the fibular artery does not have a direct connection to the plantar arch, the clinical result of fibular artery PTA is dependent upon the extent of collateralization at the ankle. Therefore, successful PTA of the fibular artery with resulting biphasic doppler waves at the ankle can lead to either biphasic or monophasic post-occlusive doppler wave patterns at the forefoot. We evaluated prospectively the association of the forefoot doppler wave form on long-term clinical outcome in patients with DFS after successful PTA of the fibular artery. PATIENTS AND METHODS: 44 patients with occluded calf vessels and DFS Wagner 2-4 underwent primary successful fibular artery PTA resulting in biphasic ankle doppler wave. According to doppler wave form at the forefoot, patients were divided into 1) a biphasic or 2) a monophasic group. Up to 45 months, we documented doppler wave forms, clinical course, restenosis, reinterventions, wound healing, major- and minor amputations. RESULTS: PTA resulted in a biphasic doppler wave at the forefoot in 26 (59 %), in 18 (41 %) in a monophasic wave pattern. Biphasic forefoot doppler wave was strongly correlated with longer event-free survival (35 bi- vs. 5.5 months monophasic, p = 0.0018) and complete wound healing (69 % s bi- vs. 44 % vs. monophasic p = 0.0309). Major amputations: 2 / 26 (8 %) in the biphasic and in 3 / 18 (17 %) in the monophasic group. Second revascularisation procedures were more often necessary in the monophasic group (7 / 18 (39 % vs. 2 / 26 (8 %)). CONCLUSION: After successful PTA of the fibular artery, monophasic doppler wave patterns at the forefoot denote insufficient collateralization and are associated with poor outcome. If successful fibular artery PTA results only in monophasic forefoot doppler, additional crural or pedal bypass should be strongly contemplated.

[Acute ischemia of the hand after intra-arterial injection of flunitrazepam. Local combined fibrinolysis therapy in three cases]. / Akute Ischämie der Hand nach intraarterieller Flunitrazepaminjektion. Lokale kombinierte Lysetherapie in drei Fällen.

HISTORY AND ADMISSION FINDINGS: Three drug addicts presented as emergencies with severe pain in one hand. 1 to 3 hours previously they had accidentally injected dissolved flunitrazepam tablets intra-arterially. The affected hands were pale and cold. Two of the patients had injected into the brachial artery, one into the radial artery. DIAGNOSTICS: The brachial and radial arteries were palpable in all three patients, but immediate angiography showed complete occlusion of all arteries to the hand and fingers. TREATMENT AND COURSE: Initial local treatment with intra-arterial infusion of prostanoids (PGE(1)) did not improve hand perfusion. Subsequently, a combination of PGE(1) and local fibrinolytic therapy with rt-PA was given intra-arterially over 12 to 22 hours. In two of the patients complete reperfusion was achieved, but one, in whom the delay between injection and treatment had been the longest, lost the distal phalanges of digits 1, 2 and 3. No bleeding complications were observed. CONCLUSION: Peripheral ischemia as a result of an accidental intra-arterial injection of dissolved tablets in drug addicts is an emergency which requires immediate action. The combined administration of prostanoids and rt-PA-lysis is a promising therapeutic option that should be employed in such patients.

[Treating chronic occlusive arterial disease]. / Stadiengerechte Therapie der chronisch arteriellen Verschlusskrankheit: "Wenn nur das Bein dran bleibt"!

The basis for the treatment of chronic occlusive arterial disease, in whatever stage, is the management of the cardiovascular risk factors as a secondary preventive measure. In the absence of contraindications, every symptomatic POAD patient should be given an antiplatelet agent. In stage I disease, prevention of progression is the overriding aim. In stage II, risk factor management and an antiplatelet agent are indicated. In addition to a walking exercise program, the reconstruction of occluded vessels may be indicated. The decision to apply interventional treatment or vascular surgery in stage II and IV disease; must be based on the morphology of the vascular lesion and concomitant diseases. If revascularization is not possible, treatment with PGE1 is recommended. As a life-saving measure when all else has failed, an amputation must be done.

Thrombin-antithrombin complex and the prothrombin fragment in arterial and venous blood of patients with peripheral arterial disease.

BACKGROUND: Thrombin generation has recently been recognized as an important factor in the development of arterial occlusive disease in all vascular provinces. Several reports concerning markers of thrombin generation have been published with however, conflicting results. It has been demonstrated in vitro that accelerated blood flow velocity causes increased thrombin generation via higher shear rates. In recent articles TAT and F1 + F2 concentrations are reported significantly higher in arterial than in venous blood. A correlation with the severity of atherosclerosis or specially with the stage of PAD was expected. In the present investigation we additionally collected blood from the femoral vein. PATIENTS AND METHODS: In 11 patients with Fontaine stages IIb to IV and two healthy subjects TAT and F1 + F2 concentrations were determined in blood samples from the femoral artery, the femoral vein (diseased leg) and cubital vein. In all cases and at all puncture sites exactly the same atraumatic technique of venipuncture was used. RESULTS: The concentrations of TAT and F1 + F2 were significantly elevated in patients with PAD. There was no significant difference between the concentrations of TAT and F1 + F2 in arterial (femoral artery) and venous (femoral vein and cubital vein) blood. CONCLUSION: The results from previous investigations have been confirmed only partially. Differences in the puncture techniques to collect arterial or venous blood result in an increased scattering of the data and a systematic error.

[Highly resistant pathogens in patients with diabetic foot syndrome with special reference to methicillin-resistant Staphylococcus aureus infections]. / Erfahrungen im Umgang mit hochresistenten Keimen bei Patienten mit diabetischem Fuss-Syndrom unter besonderer Berücksichtigung von MRSA-Infektionen.

BACKGROUND AND OBJECTIVE: Patients with diabetic foot infection (DFI) have a high rate of infection, up to 40%, with methicillin-resistant Staph. aureus (MRSA). Having noticed a definite increase of such patients in our special unit, we initiated a drastic change of hygienic measures and here report the results. PATIENTS AND METHODS: 788 patients with DFI (mean age 67.3 [32-90] years, 62% males) were admitted between 1.1.1999 and 31.7.2000. Before 31.7.1999, the following hygienic measures had been in place: cohort isolation, protective closing, implementation of general hygienic rules. Since 1.8.1999, modified measures have been undertaken: primary single-patient isolation, concentration in one ward of all patients with MRSA, medical care only by trained personnel, admission of patients only after microbiological results were known or primary solitary isolation. Algorithms were used for the transmission of all necessary information. RESULTS: MRSA was demonstrated in 64 patients. The number of infections during the hospital stay, before and after the change of hygienic measures were 9 (27%) and 2 patients (8%), respectively. The sites of MRSA colonisation and proven eradication were: nasopharynx only, 3 with 67% eradication; MRSA in a wound, 25 with 28% eradication. In comparison to the yearly statistic on wound healing in DFI 1999 (n=613) the following results are shown (patients with MRSA in brackets): healing rate with conservative treatment 61.5% (20%), minor-amputation 30.5% (52%), major-amputation 4.5% (22%), death 3.5% (6%). CONCLUSIONS: The rate of new infections were dramatically reduced by changing the hygienic measures. The rate of successful sanitation was unsatisfactoy. Patients with MRSA showed markedly poorer treatment results in respect to wound healing.

The role of microcirculatory techniques in patients with diabetic foot syndrome.

BACKGROUND: Diabetic foot syndrome (DFS) is a frequent complication of long-standing diabetes mellitus, occurring in 10 to 30 percent of all diabetics with a vital risk for the affected limb and high mortality rates. Macroangiopathy, diabetic polyneuropathy and infections are trigger factors for DFS. Recent results imply a pathogenic role of functional and structural microcirculatory changes. The exact role of microangiopathy and the value of microcirculatory diagnostic methods in DFS have not yet been defined. PATIENTS AND METHODS: 78 patients with DFS (28 type I, 50 type II diabetics, mean age 63 years) were evaluated with video capillary microscopy, transcutaneous partial oxygen tension (tcpO2) measurement and laser Doppler fluxmetry (LDF) at the forefoot of the affected leg at admission and after revascularisation. Mean hospital stay was 28 +/- 11.7 days. Patients were stratified according to the etiology of DFS in patients with neuropathic lesions, macroangiopathic ulcers and mixed neuropathic-angiopathic lesions. RESULTS: All groups had impaired microcirculation, and significant differences between groups were found in respect to capillary density. Reactive hyperemia, LDF pattern and tcpO2 did not differ significantly. Microcirculatory examinations did not yield additional information to clinical and Doppler sonographic results. CONCLUSION: In clinical practice, the role of microcirculation evaluation techniques for diabetic foot syndrome is limited.

[Dilatation tracheotomy after Ciglia--its use in an internal-medicine intensive care unit]. / Dilatationstracheotomie nach Ciaglia--Einsatz auf einer internistischen Intensivstation.

BACKGROUND AND OBJECTIVE: Since the first description of percutaneous dilatation tracheostomy (DTT), it has become an alternative method of equal value to surgical tracheostomy. This study collected the experience with DTT in a medical intensive care unit (ICU), with special reference to early and late complications and their management, outcome, and changes in ventilation parameters and blood gases. PATIENTS AND METHODS: Between March 1994 and April 1998, 74 DTTs were performed on 71 patients (52 men, 19 women; mean age 61.8 [30-80]) years. The admission or main diagnoses were cardiovascular disease in 34 patients, pulmonary disease in 21, the remainder having had a variety of conditions. RESULTS: The procedure caused complications in 21 procedures (28%): 10 cases of stomal bleeding (13.5% of total number of procedures), 2 of intratracheal bleeding (2.7%), 2 of severe tracheal injury (2.7%) and mediastinal emphysema in 1 (1.3%). None required intervention because of these complications. 38 patients were discharged from hospital. Cause of death in the other 33 was unrelated to the DTT. One patient developed tracheomalacia as a late complication. Ventilatory parameters and blood gases 12 hours post-DTT were the same as before the procedure. CONCLUSIONS: Ciaglia's method of dilatation tracheostomy is a safe procedure also in the context of a medical ICU, if the indications are correct and the procedure performed by experienced personnel. Compared with surgical tracheostomy it significantly reduces the burden on the patient as well as requiring fewer personnel and less equipment.

Therapy of severe diabetic ketoacidosis. Zero-mortality under very-low-dose insulin application.

OBJECTIVE: Despite modern concepts in therapy by low-dose insulin application and better care in intensive care units (ICUs), there still is a mortality of 5-10% for severe diabetic ketoacidosis (DKA). The aim of this study was to develop a therapy concept to reduce complications and mortality in DKA. RESEARCH DESIGN AND METHODS: From 1986 to 1997, 114 consecutive patients (mean [range]; age 34 [11-74] years) with type 1 diabetes suffering from severe DKA were treated on ICUs and investigated in a retrospective and prospective study. The following are the criteria for admission onto ICUs: < 7.20 pH level, > 300 mg/dl blood glucose, less than -12 mmol/l base excess, or < 300 mg/dl blood glucose plus severe symptoms (i.e., coma). We treated patients according to the following concepts: very-low-dose insulin application by a basal insulin infusion of 1 U/h (0.5-4.0 U/h i.v.), maximal decrease of blood glucose level by 50 mg. dl-1. h-1, slow-motion reequilibration by fluid substitution of 1,000 ml/h (Ringer-Lactate, NaCl 0.9% or half-electrolyte fluids) in the first 4 h, potassium replacement and heparin (500-1,000 U/h i.v.). RESULTS: When patients were admitted to ICU, we found the following parameters: mean (range); 609.0 (86.0-1,428.0) mg/dl blood glucose level; 7.13 (6.53-7.36) pH level; and -19.7 (-41.2 to -7.0) mmol/l base excess. After 12 h of treatment, we reached the following parameters: mean values; 251 mg/dl blood glucose level, 7.31 pH level, and -9.37 mmol/l base excess level. All patients survived without any lasting deficiencies or fatal complications. CONCLUSIONS: Very-low-dose insulin application and slow-motion reequilibration plus monitored substitution of electrolytes are the basic strategies in the treatment of severe DKA. In our view, small doses of infused insulin are the main reason for the safe results of this therapy program.

Comparison of haemostatic parameters in arterial and venous blood from patients with peripheral arterial occlusive disease.

BACKGROUND: Several studies proved the co-existence of peripheral arterial occlusive disease (PAOD) and hypercoagulability. However, in practice coagulation parameters are mainly determined from venous blood samples. In this study several coagulation parameters in arterial and venous blood were examined for differences and the validity of coagulation parameters determined in venous blood was investigated. PATIENTS AND METHODS: In 22 patients with peripheral artery disease venous and arterial blood samples from vessels of the diseased leg were examined for the concentration of thrombine-antithrombine III-complex (TAT), prothrombin fragments (F1 and F2) and D-dimers, and results were compared. RESULTS: Mean concentrations of TATs and prothrombin fragments F1 and F2 were significantly higher in arterial than in venous blood. TAT-complex was the most sensitive parameter for quantification of thrombin generation. D-dimer levels did not differ in arterial and venous blood. TAT and F1 and F2 concentrations in arterial and venous blood did not correlate in individual patients whereas D-dimer concentration did. CONCLUSION: The determination of TAT and F1 + F2 in venous blood does not adequately reflect the degree of the local coagulation activation in the arterial system. As indicators for hypercoagulability, D-Dimer values are less sensitive than F1 + 2, but venous D-dimer concentrations mirror arterial levels.

Correlation between rheological parameters and erythrocyte velocity in nailfold capillaries in patients with diabetes mellitus.

Increased rheological parameters and disturbances of capillary perfusion are often observed in both types of diabetes. It is assumed that these alterations might be involved in the development and progression of diabetic microangiopathy. It has been shown elsewhere, that erythrocyte rigidity, erythrocyte and platelet aggregation, plasma viscosity and leucocyte adhesion are increased. By methods of microcirculation capillary perfusion can be investigated and in vivo no significant alterations can be found at rest. During reactive hyperemia flow reduction diminishes capillary perfusion in various organs. In this presentation hemorheological parameters and erythrocyte velocity in nailfold capillaries are investigated in both types of diabetes under various conditions. Plasma viscosity and spontaneous platelet aggregation are often increased, especially in patients with diabetes type 2 and in diabetic foot lesions. Improvement of the metabolic situation by insulin application reduces the elevated parameters and improves capillary perfusion. Long-term type 1 diabetics tend to show increased rheological factors and reduced capillary perfusion. Although an association between some hemorheological parameters and capillary perfusion seems to exist, a strong correlation cannot be found.

Greater reduction of urinary albumin excretion in hypertensive type II diabetic patients with incipient nephropathy by lisinopril than by nifedipine.

A double-blind, randomised, parallel group, multicentre, multinational study compared the effects of 12 months' treatment with lisinopril (10-20 mg once daily) or nifedipine retard tablets (20-40 mg twice daily) in 239 males (aged 18-75 years) and 96 post-menopausal females (aged 40-75 years). They all had a history of clinically stable type II diabetes > 3 months, microalbuminuria and early diabetic nephropathy (a urinary albumin excretion (UAE) rate ranging from 20 to 300 micrograms/min) and a sitting diastolic blood pressure (DBP) 90-100 mm Hg (Korotkoff phase V) inclusive at both entry and after 3-4 weeks' placebo treatment. The aim of treatment was to achieve a reduction in sitting DBP to < 90 mm Hg 24-30 h after the last dose of lisinopril or 12-18 hours after the last dose of nifedipine and to evaluate the effect of these treatments on UAE over 12 months. The effect of the two treatments on ambulatory blood pressure (BP) was also evaluated in a subset of patients. Management of diabetes with oral hypoglycaemic drugs, diet and insulin alone or in combination was permitted. Median UAE fell on lisinopril from 65.5 (range 20-297) micrograms/min at baseline to 39.0 (2-510) micrograms/min after 12 months. On nifedipine median UAE fell from 63.0 (range 20-289) micrograms/min at baseline to 58.0 (9-1192) micrograms/min after 12 months. The estimated median difference between the effects of the two treatments was 20 micrograms/min (P = 0.0006). Over 12 months both treatments produced similar falls in sitting BP from 163 +/- 17/99 +/- 6 mm Hg (mean +/- s.d.) to 147 +/- 18/88 +/- 10 mm Hg for lisinopril and from 161 +/- 18/97 +/- 5 mm Hg to 150 +/- 18/88 +/- 9 mm Hg for nifedipine. Ambulatory BP was assessed in a subset of patients and using areas under the BP-time curve (AUC) a comparison of the effects of the two treatments showed no between-treatment differences. Creatinine clearance, glycaemic control (HbA1c) and lipid profiles did not change significantly during either treatment. Frequency of withdrawals and adverse events were similar for both treatments. We conclude that lisinopril has a significantly more beneficial effect on UAE than nifedipine despite similar effects on both BP and glycaemic control in type II diabetic patients with hypertension.

Influence of deproteinized hemodialysate on rest pain and walking distance in the presence of peripheral chronic arterial occlusive disease.

In a controlled and randomized single-blind study (blind observer) the clinical efficacy of intra-arterial therapy with a metabolically active deproteinized dialysate from calf blood has been tested against a vasodilating and hemorheologically active reference substance (bencyclan). Over a period of four weeks 28 patients each received 20 intra-arterial infusions of the deproteinized hemodialysate 20% for infusion. The reference group with 30 patients was treated with 250 mg bencyclan in 250 mL saline 0.9%. As for the target criteria, rest pain and consumption of analgesics, the hemodialysate treatment proved superior to the therapy with the reference substance. Both preparations induced to a small extent pain-free walking distances: hemodialysate group, 29.2 +/- 14.6 m; reference group, 25.8 +/- 18.7 m (group difference not significant).

[Hemorheologic therapy of asystematic vertigo]. / Hämorheologische Therapie des asystematischen Schwindels.

UNLABELLED: Hemorheological Treatment in Vertigo. Depending on data of hemorheology disturbances in risk factors (1.2.3.) and carotid artery arterosclerosis--progression in vertigo of non-vestibular origin (4.) this study evaluates treatment effects by basis, i.e. correction of risk factors only, versus additional hemorheological treatment (Lowering hct., HAES, Pentoxifylline) Patients: N = 88 fe. 51 m 37 age 25-86 mean 65.1. RESULTS: ++ base gr. 35% hemorh. 62% + base gr. 40% hem. 38% no effect base gr. 25% hemorh none.

[Arterial hypertension and hemorheology: the effects of triamterene and hydrochlorothiazide]. / Arterielle Hypertonie und Hämorheologie: Der Einfluss von Triamteren und Hydrochlorothiazid.

Ten patients with arterial hypertension and chronic heart failure (stages NYHA I and II) were treated in a pilot study with a combination of 50 mg triamteren and 25 mg of hydrochlorothiazide for 20 days under clinical conditions. The purpose of this investigation was to determine hemorheological alterations in comparison with initial data after treatment with a common diuretic combination. The influence of the therapy on hematocrit, number of leucocytes and thrombocytes as well as fibrinogen-mediated hemorheological parameters was not significant. Statistically significant (p = 0.0215) was the improvement of erythrocyte-fluidity, which indicates a positive influence of the diuretic combination on the erythrocyte membrane. Furthermore a very effective, statistically significant (p less than 0.05) decrease of blood pressure appeared, even down to a normal standard. Discussions on negative effects of diuretic therapy on hemoconcentration hitherto reported in literature are not attempted by this investigation.

Incidence of arteriosclerotic lesions of the carotid arteries in chronic peripheral arterial disease and myocardial infarction.

UNLABELLED: Arteriosclerotic lesions in the carotid arteries are the main cause of ischemic cerebral infarction. Only a few studies of the incidence of carotid lesions in patients with chronic peripheral arterial disease (CPAD) and myocardial infarction (MI) have been made. Thus the aim of this study was to investigate the pathoanatomy of the carotid arteries in a representative number of patients suffering from CPAD or MI by using highly sensitive and specific noninvasive methods. RESULTS by other authors are discussed. The authors' own study of cerebrovascular disease (CD), which covers epidemiologic aspects, is presented. METHODS: "duplex scanning" and continuous-wave Doppler ultrasound. PATIENTS: myocardial infarction, N = 73; chronic peripheral arterial disease, N = 112; cerebrovascular disease, N = 73. RESULTS: MI: stenosis greater than 50% N = 31 (42.4% of cases) - in the case of recurring infarction 67.8% of cases; CPAD: stenosis greater than 50% N = 54 (48.2%); CD: stenosis greater than 50% N = 35 (48%).

[Blood rheology in peripheral occlusive disease. Effects of hemodilution and pentoxifylline]. / Blutrheologie bei peripherer Verschlusskrankheit. Effekte von Hämodilution und Pentoxifyllin.

The understanding of rheological relations in peripheral chronic arterial occlusive disease gained in the past two decades allows the conclusion that an efficient conservative therapy may be realized by rheological measures even in advanced states of this vascular disease. The points of therapeutic approach are the flow properties or the fluidity of the blood. The therapeutic objective consists in the improvement of the microcirculation by restoring perfusion reserves for the formation of collaterals. Employment of hemodilution and administration of the rheologically active drug pentoxifylline are quoted as exemplary possibilities for a promising treatment. The therapeutic procedures must also include consequent elimination of risk factors and should bear in mind correction of hypercoagulation in order to counteract the progression of the disease.

Blood flow properties and walking performance in chronic arterial occlusive disease.

Recent investigations suggest an interdependence between blood fluidity and walking performance in patients with peripheral arterial occlusive disease (PAOD). Therefore, various blood fluidity variables (erythrocyte aggregation, erythrocyte flexibility, plasma viscosity, plasma proteins) were studied in groups of healthy subjects and claudicants with severe PAOD (exhausted perfusion reserve) receiving intravenous treatment with Trental (600 mg Pentoxifylline b.i.d., 21 days). Erythrocyte flexibility (expressed by filterability through micropore filters), red cell aggregation and plasma viscosity deteriorate with progression of disease especially in Stage IIb and III Fontaine classification, with walking distance below 150 m. Trental treatment resulted in patients with advanced POAD stages in improvement of red cell filterability, red cell aggregation, decrease of plasma viscosity, increase in absolute walking distance and relief from rest pain, suggesting that such patients are accessible to conservative treatment with hemorheologically active agents.