Ultrasound-guided thrombin injection for the treatment of iatrogenic pseudoaneurysm of the femoral artery.

BACKGROUND: Pseudoaneurysm occurring after catheterization of the femoral artery is associated with significant morbidity. Percutaneous ultrasound-guided thrombin injection has recently emerged as a potential first-line therapy. OBJECTIVES: To evaluate the efficacy of this treatment in eight patients with iatrogenic femoral artery pseudoaneurysm. METHODS: After attempted treatment with external compression had failed, eight patients with iatrogenic femoral artery pseudoaneurysm were treated with thrombin injection. Treatment performed between 2 and 9 days following arterial puncture. The study group comprised seven males and one female ranging in age from 23 to 89 years (median 70). Seven had undergone cardiac catheterization with or without intervention, and five were receiving antiplatelet and/or anticoagulant drugs. Arterial pseudoaneurysm resulted from femoral vein catheterization in one patient. Using a sterile technique and real-time Doppler ultrasound guidance, a dilute solution of bovine thrombin (average dose 250 units, range 100-600), was slowly injected directly into the pseudoaneurysm until cessation of flow was seen. Patients were allowed to walk within 2 hours of the procedure and were followed up clinically and by color Doppler ultrasound during the admission. RESULTS: Cardiac catheterization had been inadvertently performed via the superficial or profunda femoris arteries in four of the eight patients. Thrombin injection was initially successful in all eight patients without complication. Thrombosis occurred immediately in every case. Early recanalization of pseudoaneurysm occurred in one patient despite repeat thrombin injection and attempted ultrasound-guided compression. He eventually required surgical repair. The final success rate was 87.5% (7/8). CONCLUSION: Faulty puncture technique is an important risk factor for the development of post-catheterization femoral artery pseudoaneurysm. Ultrasound-guided thrombin injection is a safe, rapid, well-tolerated, inexpensive and successful therapy. If initial external compression with a sandbag fails to result in thrombosis of the pseudoaneurysm then thrombin injection should be considered as first-line therapy. If unsuccessful, it does not preclude the use of alternative treatment modalities. Further study is necessary to assess the long-term effects of thrombin injection.

Myocardial infarction after vascular surgery: the role of prolonged stress-induced, ST depression-type ischemia.

OBJECTIVES: The goal of this study was to investigate the nature of the association between silent ischemia and postoperative myocardial infarction (PMI). BACKGROUND: Silent ischemia predicts cardiac morbidity and mortality in both ambulatory and postoperative patients. Whether silent stress-induced ischemia is merely a marker of extensive coronary artery disease or has a closer association with infarction has not been determined. METHODS: In 185 consecutive patients undergoing vascular surgery, we correlated ischemia duration, as detected on a continuous 12-lead ST-trend monitoring during the period 48 h to 72 h after surgery, with cardiac troponin-I (cTn-I) measured in the first three postoperative days and with postoperative cardiac outcome. Postoperative myocardial infarction was defined as cTn-I >3.1 ng/ml accompanied by either typical symptoms or new ischemic electrocardiogram (ECG) findings. RESULTS: During 11,132 patient-hours of monitoring, 38 patients (20.5%) had 66 transient ischemic events, all but one denoted by ST-segment depression. Twelve patients (6.5%) sustained PMI; one of those patients died. All infarctions were non-Q-wave and were detected by a rise in cTn-I during or immediately after prolonged, ST depression-type ischemia. The average duration ofischemia in patients with PMI was 226+/-164 min (range: 29 to 625), compared with 38+/-26 min (p = 0.0000) in 26 patients with ischemia but not infarction. Peak cTn-I strongly correlated with the longest, as well as cumulative, ischemia duration (r = 0.83 and r = 0.78, respectively). Ischemic ECG changes were completely reversible in all but one patient who had persistent new T wave inversion. All ischemic events culminating in PMI were preceded by an increase in heart rate (delta heart rate = 32+/-15 beats/min), and most (67%) of them began at the end of surgery and emergence from anesthesia. CONCLUSIONS: Prolonged, ST depression-type ischemia progresses to MI and is strongly associated with the majority of cardiac complications after vascular surgery.

Preoperative dipyridamole-thallium scanning, selective coronary revascularization and long-term survival in patients with critical lower limb ischemia.

BACKGROUND: A large proportion of patients with critical limb ischemia have advanced, often asymptomatic coronary artery disease which is associated with increased perioperative risk and decreased long-term survival. METHODS: We evaluated retrospectively the short and long-term effect of routine dipyridamole-thallium cardiac scanning (DTS) and selective coronary revascularization in 113 consecutive patients who were scheduled for revascularization of the lower extremity. RESULTS: DTS was abnormal in 60 (53.1%) patients and demonstrated a moderate-severe reversible defect in 26 (23.0%) patients. On the basis of DTS and clinical evaluation 33 (29.2%) patients were referred for coronary catheterization. Of these, 9 underwent PTCA and 4 underwent coronary artery bypass, without complications. Surgical revascularization of the limbs was performed in all but two patients. Two (1.8%) patients died postoperatively, three (2.7%) sustained nonfatal postoperative myocardial infarctions. None of the patients who underwent preoperative coronary revascularization suffered a cardiac complication after the peripheral vascular operation. During mean follow-up of 31.7 months, 30 (28.0%) patients died. A moderate-severe reversible defect on DTS was the strongest predictor for shortened survival (Exp(b)=0.61, CI 95%=0.42-0.88; p=0.006). Patients who underwent preoperative coronary revascularization followed a survival curve approaching those without a reversible defect on DTS (mean survival 61+/-8 vs 63+/-4 months; NS) which was significantly better than those with such a defect who did not undergo coronary revascularization (mean survival 34+/-5 months; p=0.03). CONCLUSIONS: While the perioperative benefits of routine preoperative DTS screening in patients with critical limb ischemia, remain debatable, it provides an opportunity for identification and treatment of life-limiting coronary artery disease and improving survival.

Preoperative thallium scanning, selective coronary revascularization, and long-term survival after carotid endarterectomy.

BACKGROUND AND PURPOSE: Long-term survival in patients after carotid endarterectomy (CEA) is determined mainly by their concomitant cardiac disease. We tested to determine whether preoperative thallium scanning (PTS) and subsequent selective coronary revascularization (CR), by either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG), improve long-term survival after CEA. METHODS: Two hundred twenty-six of 255 consecutive patients (88%) undergoing CEA from 1990 to 1996 had PTS. Those with significant reversible defects on PTS were referred for coronary angiography and possible CR. Patients who had undergone PTS were divided into the following 4 groups: group 1, normal or mild defects on PTS; group 2, moderate-severe fixed and/or reversible defects in patients who did not undergo CR; group 3, patients who had CR secondary to their PTS results; and group 4, patients who had CR in the past that was not related to the PTS. Perioperative data were prospectively recorded, and data on long-term survival and cardiac and neurological complications were collected. RESULTS: Seventy-seven patients (34%) had preoperative coronary angiography, and 42 (19%) had subsequent CR: preoperative PTCA or CABG in 24, combined CEA+CABG in 10, and post-CEA CABG in 8 patients. No deaths resulted from the coronary angiography, CR, or CEA. Six patients had perioperative nonfatal myocardial infarction and 8 had stroke. During the follow-up (40+/-23 months), 47 patients (18%) died, 31 (66%) from cardiac disease and 4 (8.5%) from stroke. Independent predictors of long-term overall mortality were diabetes mellitus, preoperative T-wave inversion on ECG, lower-extremity arterial disease, and history of neurological symptoms [exp(beta)=3. 5, 3.4, 2.5, and 2.4; P=0.0003, 0.0004, 0.01, and 0.04, respectively]. In addition, preoperative moderate-severe thallium defect without CR (group 2) independently predicted long-term cardiac mortality [exp(beta)=2.8; P=0.04]. Patients with preoperative CR (group 3) had long-term survival rate similar to that of group 1 and significantly better than that of group 2 (P=0. 02). CONCLUSIONS: PTS predicts long-term survival, and selective CR based on the thallium results improves the survival rate of patients undergoing CEA.

Results of reconstruction in major pelvic and extremity venous injuries.

PURPOSE: Outcome and venous patency after reconstruction in major pelvic and extremity venous injuries was studied. METHODS: We retrospectively reviewed 46 patients with 47 venous injuries. RESULTS: Injuries were caused by penetrating trauma in 37 extremities, blunt trauma in 6 patients, and were iatrogenic in 4 patients. Pelvic veins were injured in 4 patients, lower-extremity veins were injured in 39 limbs in 38 patients, and upper-extremity veins were injured in 4 patients. Concomitant arterial injuries occurred in 37 patients. Venous repairs were mostly of the complex type and included spiral or panel grafts in 15 (32%) reconstructions, interposition grafts or patch venoplasty in 19 (40%) reconstructions, end-to-end and lateral repair in 11 patients, and ligation in 2 patients. Two patients underwent early amputation. Early transient limb edema occurred in 2 patients, and postoperative venous occlusions were documented in 4 patients. Full function was regained in 39 (81%) extremities. No variable, including 4 retrospectively applied extremity injury scores (mangled extremity severity score [MESS], limb salvage index [LSI], mangled extremity syndrome index [MESI], predictive salvage index [PSI]), correlated with outcome. High values on all 4 scores were significantly associated with reexplorations (P <.02), which were done in 8 patients for debridement (5), arrest of bleeding (2), and repair of a missed arterial injury (1). Follow-up of 28 +/- 6 months on 27 patients (57%; duplex scan in 18, continuous-wave Doppler and plethysmography in 9, and venography in 3) showed 1 occlusion 6 weeks after the injury and patency of all other venous reconstructions. CONCLUSION: Reconstructions of major venous injuries with a high rate of complex repairs result in a large proportion of fully functional limbs and a high patency rate. A high extremity injury score predicts the need for reexploration of the extremity. Mostocclusions occur within weeks of injury, and the subsequent delayed occlusion rate is very low.

Mesenteric bypass for chronic mesenteric ischaemia.

Chronic mesenteric ischaemia is an uncommon disease that requires treatment to relieve the symptoms of abdominal angina and to prevent intestinal infarction. Over a period of 3 years, 12 patients with visceral artery stenosis or occlusion were referred to the authors' service and 10 underwent mesenteric bypass grafting. Both the coeliac and the superior mesenteric arteries were revascularized in four patients, and the superior mesenteric artery alone in six patients, using a variety of grafts and graft configurations. This was done in conjunction with aortic graft placement in four cases and with renal bypass in three. All patients survived the procedure. At a mean follow-up of 28 months, one patient died of myocardial infarction 42 months after surgery, while all survivors are symptom-free. Chronic mesenteric ischaemia can be treated safely and effectively. The variation in the pattern of mesenteric occlusions and the frequent association with aortic and renovascular disease does not allow for a single 'best' technical solution but requires the surgical procedure to be individually tailored.

Perioperative ischemia and cardiac complications in major vascular surgery: importance of the preoperative twelve-lead electrocardiogram.

PURPOSE: To investigate the associations between specific preoperative 12-lead electrocardiogram (ECG) abnormalities, perioperative ischemia, and postoperative myocardial infarction or cardiac death in major vascular surgery. METHODS: Two prospective studies on perioperative myocardial ischemia performed in two tertiary university hospitals were combined to include 405 patients. All preoperative ECGs were analyzed according to the Sokolow-Lyon criteria for left ventricular hypertrophy by investigators who were blinded to the patients' perioperative clinical course. Perioperative myocardial ischemia was detected by continuous ECG recording, and postoperative cardiac complications included myocardial infarction and cardiac death. RESULTS: A total of 19 postoperative cardiac complications occurred (two cardiac deaths and 17 myocardial infarctions). Voltage criteria for left ventricular hypertrophy (78 patients, 19%) and ST segment depression greater than 0.5 mm (98 patients, 24.2%) on preoperative ECGs were both significantly associated with postoperative myocardial infarction or cardiac death (odds ratio, 4.2 and 4.7; p = 0.001 and 0.0005, respectively) and with longer intraoperative and postoperative myocardial ischemia. In each of the two study groups, a preoperative ECG abnormality that involved voltage criteria, ST segment depression, or both (134 patients, 33.1%) was more predictive of postoperative cardiac complications than any other preoperative clinical variable, including a history of myocardial infarction or angina pectoris, diabetes mellitus, pathologic Q-wave by ECG, or preoperative myocardial ischemia. The combined duration of intraoperative and postoperative ischemia and the preoperative ECG with either voltage criteria or ST segment depression were the only independent factors associated with adverse cardiac events by multivariate analysis (p < or = 0.0001 and p = 0.02, respectively). CONCLUSION: Left ventricular hypertrophy and ST segment depression on preoperative 12-lead ECGs are important markers of increased risk for myocardial infarction or cardiac death after major vascular surgery.

Thoracic aorta transobturator bipopliteal bypass as eventual durable reconstruction after removal of an infected aortofemoral graft.

A 36-year-old man was referred with aortofemoral graft infection and perigraft duodenal erosion. The aortofemoral graft was removed, and bilateral axillo-superficial femoral grafts were constructed. Recurrent failures of these grafts prompted us to convert to a more-durable reconstruction. A straight graft was anastomosed to the lower thoracic aorta, routed retroperitoneally, and attached to an inverted U-shaped bilateral transobturator bypass graft, which was anastomosed to both above-knee popliteal arteries. After 3 years, the patient has remained well and the grafts are patent. This operation represents a durable in-line reconstruction that avoids all previously infected areas after removal of an infected aortofemoral graft.

[Treatment of concomitant coronary and carotid disease].

The optimal surgical treatment for concomitant carotid and coronary artery disease is controversial. Between 1991 and 1995 we performed 34 procedures for combined disease of the carotid and coronary arteries. The first 8 operations were carotid endarterectomies followed by coronary artery bypass grafting (staged procedure). The next 26 operations were performed during a single anesthesia (combined procedure). The patients were 28 men and 6 women, aged 58-81 years (mean 68). 80% were in functional class III or IV. In 40% ventricular function was moderately or severely reduced. There was an average of 3.6 grafts per patient, and in all except 3 patients the left internal thoracic artery was used as a conduit for coronary artery bypass grafting. 30% had symptomatic carotid stenosis; there was no perioperative mortality. In the staged procedure group, 2 patients had postoperative cardiac complications: in 1 acute coronary insufficiency and acute myocardial infarction in the other. 1 had postoperative, transient, amaurosis fugax. In the combined procedure group, 1 had a myocardial infarction and 1 a minor occipital stroke. During follow-up, 1 patient died 4 months after operation of myocardial infarction, and 1 had a minor stroke. The results suggest that the combined procedure is safe and carries low risk of both mortality and morbidity. Whenever cardiac disease is stable and there is no main coronary artery disease, a staged procedure should be considered. In any other situation we continue to perform the combined procedure.

Insulin-like growth factor-I (IGF-I) and IGF-I receptor gene expression in the kidney of the chronically hypoinsulinemic rat and hyperinsulinemic rat.

Acute streptozotocin (STZ)-induced diabetes in rats causes a transient increase in insulin-like growth factor-I (IGF-I) in the kidney, followed by a rapid renal hypertrophy and constant renal hyperperfusion. However, renal IGF-I levels return to normal within 4 days. Thus, hyperperfusion, which is independent of renal hypertrophy of the chronically diabetic kidney, is not explained by increased renal IGF-I. We studied IGF-I and IGF-I receptor gene expression in the kidney of rats with long-standing STZ-induced diabetes. IGF-I mRNA level in the chronically diabetic kidney was approximately 50% of that in control rats, whereas IGF-I receptor mRNA was increased approximately threefold. Ten days' treatment with insulin 65 days after induction of diabetes resulted in a glucose-dependent decrease in IGF-I receptor mRNA. Chronic hyperinsulinemia with near normoglycemia did not change gene expression of either IGF-I or IGF-I receptor. The studies suggest that glucose levels per se, independent of insulin levels, play an important role in the regulation of IGF-I receptor gene expression in the chronically diabetic kidney. Furthermore, kidney hyperperfusion in chronic diabetes is coupled with the increase in IGF-I receptor mRNA, despite normal kidney IGF-I levels.

Transient neurological events during dipyridamole stress test: an arterial steal phenomenon?

Dipyridamole-associated adverse neurological side effects have not been extensively described. We present two cases of dipyridamole-associated transient motor neurological events with no evidence of residual neurological deficits detected clinically or by head CT. The patients showed no evidence of significant extracranial (internal carotid) artery disease. We propose the presence of a regional cerebral perfusion disturbance due to an intracranial vascular steal phenomenon as the mechanism for the above side effects of dipyridamole.

Prolonged postoperative myocardial ischaemia and infarction in vascular surgery performed under regional anaesthesia.

The importance of prolonged postoperative myocardial ischaemia in cardiac outcome has recently been emphasised. The present study examines the correlation between perioperative ischaemia and myocardial infarction (MI) in patients undergoing peripheral vascular surgery (PVS) under regional anaesthesia. One-hundred-and-forty consecutive peripheral vascular operations under regional anaesthesia were prospectively analysed, using Holter monitoring for perioperative myocardial ischaemia (defined as down sloping or horizontal ST-segment depression of > or = 1 mm) and postoperative cardiac outcome. The study was approved after informed consent. There were 82 carotid endarterectomies under cervical block and 58 infrainguinal bypass procedures under continuous spinal or epidural anaesthesia. IHD was present in 53.6% cases: previous MI-38%; angina pectoris-33%; previous CABG/PTCA-24%. Holter monitoring started about 20 hours before surgery and continued for 45 hours. After surgery patients were followed for signs of cardiac complications; daily 12 lead ECG; 6 hourly CK-MB isoenzymes during the first 24 postoperative hours and later whenever indicated. MI diagnosis was based on chest pain, permanent new ECG changes and CK-MB elevation. There was no 30-day mortality. Postoperative MI occurred in seven patients (5%). Five of the postoperative MI were non-Q-wave infarctions. The majority (71%) of the adverse cardiac events started within 24 hours of surgery, and the latest occurred 52 and 72 hours post surgery. In 65 cases (46.4%) there were 259 episodes of significant ST-depression. In 75 (53.6%) cases ischaemic episodes were not detected. Patients with postoperative cardiac events had significantly more and longer ischaemic episodes in all three perioperative periods than those without such events.(ABSTRACT TRUNCATED AT 250 WORDS)

Perioperative myocardial ischemia in carotid endarterectomy under cervical plexus block and prophylactic nitroglycerin infusion.

Perioperative myocardial ischemia was evaluated in 36 consecutive carotid endarterectomy procedures carried out on patients with a high (72.2%) prevalence of ischemic heart disease. The procedures were performed under cervical plexus block plus a prophylactic intravenous nitroglycerin infusion. Findings of myocardial ischemia on perioperative (48 hours) continuous electrocardiogram recordings were correlated with preoperative cardiac status, perioperative continuous intra-arterial blood pressure measurements, and postoperative cardiac outcome. In two patients, ST segment analysis was un-interpretable because of bundle-branch blocks. Altogether, 64 episodes of significant ST segment depression were detected in 18 (52.9%) of the remaining procedures. In 8 (23.5%) procedures, ST segment depressions occurred either during carotid artery clamping at the time of the largest rise in blood pressure or within 2 hours of declamping, when blood pressure tended to decline. There were four (11.7%) postoperative cardiac events: three myocardial infarctions (one Q wave and two non-Q wave) and one episode of unstable angina pectoris. All four patients with cardiac events had early signs of myocardial ischemia either at the time of cross-clamping, or soon after declamping of the carotid artery. All myocardial infarctions developed following prolonged (> 10 hours) myocardial ischemia, starting with the first 20 hours after surgery. Thus, ST segment depression occurring during clamping or soon after carotid declamping was associated with cardiac complications (sensitivity 100% and specificity 86.6%) and suggests the possible usefulness of on-line ST segment trend monitoring.

Importance of long-duration postoperative ST-segment depression in cardiac morbidity after vascular surgery.

Major vascular surgery is associated with a high incidence of cardiac ischaemic complications. By means of continuous perioperative electrocardiographic recording, we studied 151 consecutive patients undergoing major vascular surgery to find out the characteristics of any myocardial ischaemia and the relation to outcome. 13 (8.6%) patients had postoperative cardiac events (6 myocardial infarctions, 2 unstable angina, and 5 congestive heart failure). There were 342 perioperative ischaemic episodes shown by ST-segment depression; 164 (48%) occurred postoperatively. Postoperative ischaemic episodes were significantly longer than episodes before or during operations (3.2 vs 1.7 and 1.5 min per h monitored, respectively, p < 0.001). Both Detsky's cardiac risk index and long-duration (> 2 h) preoperative ischaemia were predictive of postoperative cardiac complications (odds ratios in univariate analysis 3.3, p = 0.03, and 7.2, p = 0.009, respectively). However, long-duration (> 2 h) postoperative ischaemia was the only factor significantly associated with cardiac morbidity in multivariate logistic regression analysis (odds ratio 21.7, p = 0.001). Long-duration ST-segment depression preceded most (84.6%) postoperative cardiac events, including myocardial infarctions, and no cardiac event was preceded by ST-segment elevation. 5 of the 6 postoperative myocardial infarctions were non-Q-wave infarctions. We conclude that long-duration subendocardial ischaemia, rather than acute coronary artery occlusion, may bring about postoperative myocardial injury and complications.

Systemic embolization following thrombolytic therapy for acute myocardial infarction.

We describe a patient with acute inferior myocardial infarction who developed a "saddle" aortic embolus during streptokinase infusion. Three months previously, this patient had sustained an anterior infarction, and an apical aneurysm was found. This patient's embolus had most probably originated from a left ventricular mural thrombus that had been dislodged by streptokinase. As fibrinolytic treatment is gaining wide acceptance, physicians should be aware of this rare, but possible, complication.

Survival after ultrasonographic demonstration of portal venous gas due to mesenteric artery occlusion.

Portal vein gas as a result of bowel necrosis following occlusion of the superior mesenteric artery has an extremely grave prognosis. Only two previous cases have been recorded as having survived. In both those cases the diagnosis of portal vein gas was made on an abdominal radiograph. The present report is of the first such case surviving after ultrasonic demonstration of portal gas. In this case, no evidence of portal gas was seen on the abdominal radiograph. The increased sensitivity of ultrasound over plain radiography mandates urgent liver and portal ultrasound in all cases of suspected mesenteric event.

[Surgical treatment of chronic mesenteric ischemia].

A 44-year-old woman with chronic abdominal pain and weight loss is presented. 1 year after onset of symptoms and following multiple diagnostic procedures, angiography revealed high grade stenosis of the celiac and superior mesenteric arteries at their origins. Bypass grafts of Goretex were implanted from the infrarenal aorta to both arteries beyond the narrowed segments. 1 year after surgery the patient has regained her weight and is feeling well.