Effect of antibodies to intercellular adhesion molecule type 1 on the protection of distant organs during reperfusion syndrome in rats

We investigated kidney and lung alterations caused by intercellular adhesion molecule type 1 (ICAM-1) blockade after ischemia and reperfusion of hind limb skeletal muscles. Rats were submitted to ligature of the infrarenal aorta for 6 h. The animals were randomized into three groups of 6 rats each: group I, sacrificed after ischemia; group II, reperfusion for 24 h, and group III, reperfusion for 24 h after receiving monoclonal anti-ICAM-1 antibodies. At the end of the experiment, blood samples were collected for creatinine, lactate dehydrogenase, creatine phosphokinase, potassium, pH and leukocyte counts. Samples were taken from the muscles of the hind limbs and from the kidneys and lungs for histological analysis and measurement of the neutrophil infiltrate by myeloperoxidase staining. The groups did not differ significantly with regard to the laboratory tests. There were no major histological alterations in the kidneys. An intense neutrophil infiltrate in the lungs, similar in all groups, was detected. Myeloperoxidase determination showed that after reperfusion there was significantly less retention of polymorphonuclear neutrophils in the muscles (352 ± 70 vs 1451 ± 235 I 10² neutrophils/mg; P<0.01) and in the kidneys (526 ± 89 vs 852 ± 73 I 10² neutrophils/mg; P<0.01) of the animals that received anti-ICAM-1 before perfusion compared to the group that did not. The use of anti-ICAM-1 antibodies in this experimental model minimized neutrophil influx, thus reducing the inflammatory process, in the muscles and kidneys after ischemia and reperfusion of the hind limbs

Effect of antibodies to intercellular adhesion molecule type 1 on the protection of distant organs during reperfusion syndrome in rats.

We investigated kidney and lung alterations caused by intercellular adhesion molecule type 1 (ICAM-1) blockade after ischemia and reperfusion of hind limb skeletal muscles. Rats were submitted to ligature of the infrarenal aorta for 6 h. The animals were randomized into three groups of 6 rats each: group I, sacrificed after ischemia; group II, reperfusion for 24 h, and group III, reperfusion for 24 h after receiving monoclonal anti-ICAM-1 antibodies. At the end of the experiment, blood samples were collected for creatinine, lactate dehydrogenase, creatine phosphokinase, potassium, pH and leukocyte counts. Samples were taken from the muscles of the hind limbs and from the kidneys and lungs for histological analysis and measurement of the neutrophil infiltrate by myeloperoxidase staining. The groups did not differ significantly with regard to the laboratory tests. There were no major histological alterations in the kidneys. An intense neutrophil infiltrate in the lungs, similar in all groups, was detected. Myeloperoxidase determination showed that after reperfusion there was significantly less retention of polymorphonuclear neutrophils in the muscles (352 +/- 70 vs 1451 +/- 235 x 10(2) neutrophils/mg; P<0.01) and in the kidneys (526 +/- 89 vs 852 +/- 73 10(2) neutrophils/mg; P<0.01) of the animals that received anti-ICAM-1 before perfusion compared to the group that did not. The use of anti-ICAM-1 antibodies in this experimental model minimized neutrophil influx, thus reducing the inflammatory process, in the muscles and kidneys after ischemia and reperfusion of the hind limbs.

Effect of sequential intermittent pneumatic compression on both leg lymphedema volume and on lymph transport as semi-quantitatively evaluated by lymphoscintigraphy.

Sequential Intermittent Pneumatic Compression (SIPC) is an accepted method for treatment of peripheral lymphedema. This prospective study evaluated the effect in 11 patients of a single session of SIPC on both lymphedema volume of the leg and isotope lymphography (99Tc dextran) before SIPC (control) and 48 hours later after a 3 hour session of SIPC. Qualitative analysis of the 2 lymphoscintigrams (LS) was done by image interpretation by 3 physicians on a blind study protocol. The LS protocol attributed an index score based on the following variables: appearance, density and number of lymphatics, dermal backflow and collateral lymphatics in leg and thigh, visualization and intensity of popliteal and inguinal lymph nodes. Volume of the leg edema was evaluated by measuring limb circumference before and after SIPC at 6 designated sites. Whereas there was a significant reduction of circumference in the leg after SIPC (p<0.05), there was no significant difference in the index scores of the LS before and after treatment. This acute or single session SIPC suggests that compression increased transport of lymph fluid (i.e., water) without comparable transport of macromolecules (i.e., protein). Alternatively, SIPC reduced lymphedema by decreasing blood capillary filtration (lymph formation) rather than by accelerating lymph return thereby restoring the balance in lymph kinetics responsible for edema in the first place.

Hemodynamic results of femoral vein valve repair.

Our aim was to assess the hemodynamic and clinical responses associated with valve repair surgery in 37 patients with severe chronic venous insufficiency. Patients classified as C(4-6)E(P)A(SDP)P(R) (primary venous dysfunction with skin changes with reflux of superficial, deep and perforating veins) were submitted to a novel procedure combining the closed technique described by Kistner with the Dacron sleeve technique described by Hallberg (mean follow-up = 24 months). A significant improvement in Valsalva test results (P < 0.0001), ambulatory pressure (P = 0.0099), venous refilling time (P < 0.0001), and reflux index (P < 0.0001) was observed. Postoperative reactive hyperemia and gradient tests confirmed absence of venous obstruction signs. On their last visit, 85.3% of the patients had no ulceration, and edema was absent or minimal in over 90%. About 70% of the patients referred partial or complete relief of pain in the affected limb. The combined surgical technique was effective to control venous reflux 24 months after the procedure. A longer follow-up would be necessary to assess long-term results.

Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism.

BACKGROUND: Low molecular weight heparins have been shown to be effective and safe for prevention of venous thromboembolism. There is accumulating evidence that these new anticoagulants are also effective and safe for treatment of venous thromboembolism. OBJECTIVES: The objective of this review was to determine the effect of fixed-dose, subcutaneous low molecular weight heparins compared with adjusted-dose, intravenous or subcutaneous, unfractionated heparin for initial treatment of acute deep venous thrombosis or pulmonary embolism. SEARCH STRATEGY: Trials were identified from the Cochrane Peripheral Vascular Diseases Group trials register and LILACS. The reviewers contacted colleagues and representatives of pharmaceutical companies for additional information about trials. SELECTION CRITERIA: Randomised trials comparing fixed-dose, subcutaneous low molecular weight heparin with adjusted-dose, intravenous or subcutaneous, unfractionated heparin in patients with venous thromboembolism. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trials for inclusion and quality, and extracted data independently. MAIN RESULTS: Fourteen studies with a total of 4754 patients were included. By the end of follow up in ten trials, thrombotic complications occurred in 86 (4.3%) of the 1998 patients treated with low molecular weight heparin, compared with 113 (5.6%) of the 2021 patients treated with unfractionated heparin (odds ratio 0.76, 95% confidence interval 0.57 to 1.01). In eight trials a reduction in thrombus size was shown by 60% treated with low molecular weight heparin and 54% treated with unfractionated heparin (odds ratio 0.77, 95% confidence interval 0.61 to 0.97). At the end of the initial treatment period, in all 14 of the trials, major haemorrhages occurred in 30 (1.3%) of the 2353 patients treated with low molecular weight heparin, compared with 51 (2.1%) of the 2401 patients treated with unfractionated heparin (odds ratio 0.60, 95% confidence interval 0.39 to 0.93). By the end of follow up in 11 trials, 135 (6.4%) of the 2108 patients treated with low molecular weight heparin had died, compared with 172 (8.0%) of the 2137 patients treated with unfractionated heparin (odds ratio 0.78, 95% confidence interval 0.62 to 0.99). Five studies with a total of 1636 patients examined proximal (above the knee) thrombosis; 814 treated with low molecular weight heparin and 822 with unfractionated heparin. A sub-analysis of these trials showed statistically significant reductions favouring the action of low molecular weight heparin in three areas: thrombotic complications; major haemorrhages; and overall mortality. By the end of follow up 39 (4. 8%) patients treated with low molecular weight heparin had thrombotic complications, compared with 64 (7.8%) treated with unfractionated heparin (odds ratio 0.60, 95% confidence interval 0. 40 to 0.89). Major haemorrhages occurred in 8 (1.0%) treated with low molecular weight heparin, compared with 68 (8.3%) treated with unfractionated heparin (odds ratio 0.44, 95% confidence interval 0. 21 to 0.95). By the end of follow up, 44 (5.4%) treated with low molecular weight heparin had died, compared with 68 (8.3%) treated with unfractionated heparin (odds ratio 0.64, 95% confidence interval 0.43 to 0.93). REVIEWER'S CONCLUSIONS: Low molecular weight heparin is at least as effective as unfractionated heparin in preventing recurrent venous thromboembolism, and significantly reduces the occurrence of major haemorrhage during initial treatment and overall mortality at the end of follow-up. It can be adopted safely as the standard therapy for deep venous thrombosis, and studies comparing individual low molecular weight heparins are merited.

Percutaneous transluminal angioplasty in the treatment of renovascular hypertension: sequential prospective study.

OBJECTIVE: To evaluate the use of percutaneous transluminal renal angioplasty (PTRA) in the treatment of renal vascular hypertension. DESIGN: Sequential prospective PTRA treatment of severe arterial hypertension, screening by the captopril test, confirmed by renal arteriography, and the result evaluated by post-PTRA arteriography, blood pressure measurement and renal function. SITE: Vascular Surgery, angioradiology sector, and Nephrology outpatients department of the Federal University of São Paulo-Paulista School of Medicine, São Paulo, Brazil, a tertiary health-care institution. PARTICIPANTS: PTRA was employed on 32 patients screened by clinical examination, captopril test and renal arteriography. EVALUATION: PTRA results were evaluated by the criteria of the Cooperative Study of Renovascular Hypertension. RESULTS: After PTRA the completion arteriography showed no renal stenosis in 24 patients (75%), residual stenosis (20-50%) in 3 (9.4%) and no change in 5 (15.6%). The blood pressure results were: 3 patients (9.4%) were cured, 24 (75%) improved and 5 (15.6%) were unchanged. We observed normal renal function before and after PTRA in 25 patients (78%); altered pre- and improved post-PTRA in 2 (6.3%); post-PTRA remained unaltered in 2 (6.3%); and altered pre- and worsened post-PTRA in 3 (9.4%). Recurrence of stenosis occurred in one patient after 8 months. CONCLUSIONS: PTRA is a convenient procedure, relatively safe and an effective complementary method of medical therapy for controlling renovascular hypertension.

Ligation of the left renal vein in epm1-Wistar rats: functional and morphologic alterations in the kidneys, testes and suprarenal glands.

OBJECTIVE: The ligation of the left renal vein (LLVR) in man is a controversial procedure in view of the risks of lesion to the renal parenchyma. With the objective of studying the morphologic and functional alterations caused by these lesions, we conducted experimental research with rats. MATERIAL AND METHODS: 64 male adult EPM1-WISTAR rats were used, divided into 8 groups-4 for LLRV and four for control. Each LLRV group and corresponding control group were sacrificed progressively on the 7th, 15th, 30th and 60th day after the initial surgery. RESULTS: We found morphofunctional alterations only in animals that underwent LLRV in the four periods of sacrifice. The proteinuria creatinine in serum, testosterone in serum and serum corticosterone in serum showed practically no alteration in relation to the normal values for rats. Statistically significant severe histological lesions were found in the kidneys and testes of the LLRV groups. Lesions in the suprarenal glands were also present in these groups, but no sufficient to demonstrate statistical significance. CONCLUSION: Based on these results we can conclude that the ligation of the left renal vein is a procedure of high risk in these animals.

Hemodynamic improvement in hemorrhagic shock by aortic balloon occlusion and hypertonic saline solutions.

The initial treatment of uncontrolled hemorrhage shock from an abdominal source is controversial. The hemodynamic effects of transfemoral diaphragmatic aortic occlusion with a balloon followed by a single bolus of hypertonic saline solutions have been evaluated in 28 dogs. The animals were submitted to pressure-driven hemorrhage for 90 min, according to mean arterial pressure in the abdominal aorta and randomized into four groups, according to the treatment employed at 34 min after hemorrhage. Group 1 dogs (controls) received isotonic NaCl (0.9%, 208 mOsm/l, 4 ml/kg) without aortic occlusion; group 2 underwent aortic occlusion and received isotonic NaCl (0.9%, 308 mOsm/l, 4 ml/kg): group 3 were occluded and received hypertonic NaCl (7.5%, 2400 mOsm/l, 4 ml/kg); group 4 were occluded and received hypertonic sodium acetate (10.5%, 2400 mOsm/l, 4 ml/kg). There were no significant differences between groups at basal measures and also after 30 min of continuous bleeding, when animals presented with severe shock, and significant decreases in mean arterial pressure, cardiac index, systolic index and cardiac filling pressures; the systemic vascular resistance index was increased. Control animals remained in severe shock throughout the experiment and three died. The recovery of mean arterial pressure in aortic-occluded dogs given isotonic NaCl was associated with a marked increase in systemic vascular resistance index, without improvements in cardiac index, systolic index and cardiac filling pressures. In occluded dogs given hypertonic NaCl and NaAc the mean arterial pressure recovery lasted longer, with lower increases in systemic vascular resistance index, while the cardiac index, systolic index and cardiac filling pressures showed a marked albeit transient increase. Injection of hypertonic saline following aortic occlusion produced significantly better hemodynamic profiles and should be seriously considered for the first treatment in severe uncontrolled hemorrhagic shock from an abdominal vascular source.

Fístulas arteriovenosas braquiocefálicas e braquiobasílicas para hemodiálise: seguimento precoce e tardio / Brachiocephalic and brachiobasilic arteriovenous fistulas for hemodialysis at the early and late follow-up

Entre junho de 1985 e setembro de 1992 foram realizadas 78 fístulas arteriovenosas em pacientes portadores de insuficiência renal crônica terminal, distribuídas em dois grupos: 59 fístulas do tipo braquiocefálica, realizada em 54 pacientes, e 19 fístulas do tipo braquiobasílica com superficializaçäo da veia basílica, executadas em 18 pacientes. Os grupos foram estudados em dois períodos distintos - seguimentos precoce e tardio - e analisados em funçäo da perviedade e das complicaçöes. Os resultadosbtdiso permitem concluir que ambas as técnicas säo alternativas válidas para a manutençäo de pacientes com insuficiência renal crônica terminal em programa de hemodiálise, especialmente quando näo há condiçöes de realizaçäo ou de preservaçäo de acesso na altura do antebraço, pois apresentam poucas complicaçöes e alto índice de perviedade no seguimento tardio.

Fístulas arteriovenosas braquiocefáficas e braquiobasílicas para hemodíalise: seguimento imediato / Brachiocephalic and brachiobasilic arteriovenous fistulas for hemodialysis: immediate follow-up

Entre junho de 1985 e setembro de 1992 foram realizadas 78 fístulas em pacientes portadores de insuficiência renal crônica terminal, distribuídas em dois grupos: 59 fístulas do tipo braquiocefálica, realizadas em 54 pacientes, e 19 fístulas do tipo braquiobasílica com superficializaçäo da veia basílica, executadas em 18 pacientes. As doenças associadas mais frequentes foram a hipertensäo arterial (55,5 por cento em cada grupo) e o diabetes melito (35,2 por cento no grupo de fístula braquiocefálica 38,9 por cento no grupo de fístulas braquiobasílicas). Os grupos foram estudados nos seguintes imediato e analisados em funçäo da perviedade e das complicaçöes. Os resultados mostraram que a complicaçäo pós-operatória mais frequente foi a trombose, presente em 16,9 por cento dos casos no grupo de fístula braquiocefálica e ausente no grupo de fístula braquiobasílica (p=0,0499), no seguimento imediato. Os resultados obtidos permitem concluir que ambas as técnicas säo alternativas válidas para a manutençä e pacientes com insuficiência renal crônica terminal em programa de hemodiálise, especialmente quando näo há condiçöes de realizaçäo ou de preservaçäo de acesso ao nível do antebraço, pois apresentam poucas complicaçöes e alto índice de perviedade no seguimento imediato de 30 dias.

Upper-extremity deep venous thrombosis: analysis of 52 cases.

In a review of 52 cases of deep venous thrombosis (DVT) of the upper extremity, the predisposing factors, clinical manifestations, topography of thrombosis, treatment employed, presence of complications, and evolution of the disease were investigated. In all patients, clinical manifestations were confirmed by bilateral phlebography and superior cavography. Thirty-five (67%) of the patients were male; the mean age was 45.4 years. Clinical manifestations were edema in 51 patients (98%), dilated collateral circulation in 37 (71%), and pain in 33 (63%). One patient presented with pulmonary embolism and another with phlegmasia cerulea dolens-like signs in an extremity. The right axillosubclavian segment was involved in 23 patients (44%), the left in 17 (33%), and both left and right segments associated with DVT of the superior vena cava in 11 (21%). One patient had left and right axillosubclavian thrombosis without superior vena cava involvement. The main predisposing factors identified were central venous catheterization in 15 patients (29%) and extrinsic compression, caused mainly by cancer, in 15 (29%). There were three cases of DVT related to effort and three to thoracic outlet syndrome. The majority of patients were treated with systemic heparin therapy followed by oral anticoagulation. During a follow-up of 6 months, nine patients died, one from pulmonary embolism; 21 patients (40%) were symptom-free, 11 (21%) had minimal edema, and seven (13%) had symptomless edema. Four patients (8%) were lost to follow-up. The overall incidence of pulmonary embolism was 4%.(ABSTRACT TRUNCATED AT 250 WORDS)

The management of venous trauma: early and late results.

The result of a fifteen year study related to the management of the venous injuries in the iliac-femoro-popliteal segment have been assessed. The patients were divided in Group I--comprised 20 patients with venous revascularization and Group II--12 cases without revascularization. The early results at 30 days evaluated by the clinical examination revealed edema in all limbs without revascularization. The phlebographic patency of the revascularization was 70%. The difference between the two groups was significant (X2 = 14.93; X2 critical = 3.84). The late results were evaluated clinically in 14 patients (ranged from 6 months to 12 years) and phlebographically in 8 (ranged from 2 years to 9 years). The comparison between the two groups revealed residual edema in 5 patients of Group II as well as in 2 patients of Group I (p = 0.0105 or 1.05%). Supported in this experience we recommend the revascularization of major injured veins.

Complicaçöes do cateterismo arterial retrógrado percutâneo / Complications of percutaneous retrograde arterial catheterism

A introduçäo do cateterismo vascular pela técnica de Seldinger veio trazer um enorme avanço ao universo de exames complementares utilizados para diagnóstico na medicina. Entretanto, sendo uma técnica invasiva, esse procedimento poderia causar complicaçöes. Com o objetivo de analisar as complicaçöes envolvidas com a utilizaçäo dessa técnica, estudamos 707 pacientes submetidos a 772 cateterismos arteriais retrógrados percutâneos para diagnóstico. Verificamos a ocorrência de 74 complicaçöes (9,6) sendo 16 consideradas graves (2,1) e 58 leves(7,5). O tratamento operatório foi instituido em 15 complicaçöes vasculares graves (1,9) e medicamentoso e/ou observaçäo clínica nas complicaçöes restantes. Näo ocorreram óbitos nessa amostra

Bullet embolism following gunshot wound of the chest. Case report and review of the literature.

A 24 year old male was shot in the low left posterior chest. Initial x-rays localized the bullet in the region of the left atrium or pulmonary veins. At 24 hours the bullet embolized to the right subclavian artery, totally occluding the vessel. The bullet was successfully removed, as was adjacent thrombus with complete restoration of distal pulses. Sixty-one cases with gunshot wound to the chest and 63 arterial emboli were reviewed. There was a mortality rate of 38%.