Generation of reactive oxygen metabolites by the varicose vein wall.

OBJECTIVES: to evaluate the content of lipid peroxidation products (expressed by the concentration of thiobarbituric acid-reactive substances; TBARS), the content of myeloperoxidase (MPO), and the localisation of xanthine oxidase (XO) in varicose veins (vv), varicose veins with superficial thrombophlebitis and unchanged saphenous veins. METHODS: varicose saphenous veins, varicose veins with superficial thrombophlebitis and normal saphenous veins obtained during varicose vein surgery on 36 patients as well as healthy saphenous veins from cadaver organ donors (control). Homogenates were prepared in which TBARS concentration and MPO content were determined. Immunohistochemical staining to detect XO was also performed. RESULTS: the highest concentration of TBARS occurred in vv with superficial thrombophlebitis, the lowest in donor vein. The highest content of MPO was observed in vv and slightly lower - in varicose veins with thrombophlebitis. A positive reaction for XO was seen in vv wall endothelium. Specimens of vv with thrombophlebitis revealed strong, intense staining in endothelium as well as in vasa vasorum. CONCLUSIONS: varicose veins, especially those complicated with superficial thrombophlebitis revealed increased free radical generation. Its sources might be neutrophils, and in vv complicated with superficial thrombophlebitis-xanthine oxidase.

Glycosaminoglycans of normal veins and their alterations in varicose veins and varicose veins complicated by thrombophlebitis.

The aim of the study was to examine the content and molecular differentiation of glycosaminoglycans (GAGs) in the wall of varicose veins. The studied material consisted of normal, varicose veins and varicose veins complicated by thrombophlebitis collected during operations on 26 patients. In the wall of varicose veins the mean GAGs' content as well as the content of sulphated GAGs, except heparan sulphate was increased, whereas the amount of hyaluronic acid was decreased. Furthermore, the increased quantitative ratio between sulphated and nonsulphated GAGs was demonstrated. The results indicate an evident extracellular matrix remodelling in the wall of varicose veins particularly those complicated by thrombophlebitis, that is characterised by alterations in the content and molecular differentiation of GAGs.

[Clinical classification of diabetic foot as a guideline for selection of treatment]. / Kliniczne klasyfikacje owrzodzenia w zespole stopy cukrzycowej jako przewodnik w wyborze sposobu leczenia.

Foot ulceration in patients with diabetes mellitus is always a serious risk factor for lower limb amputation. To amputate or to continue conservative treatment is usually a very difficult decision and not without mistakes. The main objective of the study was assessment of the diabetic wound depth as a clinical guideline for decision-making of conservative or aggressive surgical treatment. Local foot ulceration and results of management of 62 diabetics were analysed. Lower leg amputations were performed in 40% of the patients. The foot wound was evaluated according to University of San Antonio or Wagner's scoring system. Conservative treatment resulted in failure in 19% of patients of grade I, 54% of grade II, 60% of grade III and 87% of grade IV according to Wagner's. Using the San Antonio classification there were 20% of amputations in grade I, 58% in grade II and 65% in grade III. Taking into account infection and peripheral vascular disease there were 37% of amputations in stage B, 41% in stage C and 80% in stage D. Data analysis of the study suggests better clinical usefulness of the San Antonio classification system in prognosis of limb salvage. There is high probability of failure in conservative treatment of diabetic foot lesion of grade II and III and in stage D according to University of San Antonio scoring system.

Coagulative and fibrinolytic activity in parietal thrombus of aortic aneurysm.

Lumen of aortic aneurysm is usually filled with parietal thrombus. Behaviour of the parietal thrombus is determined by the ratio of coagulation factors to factors of fibrinolytic system. Activity of some factors of coagulation and fibrinolysis in the parietal thrombus of aortic aneurysm was determined using coagulative, fibrinolytic and caseinolytic tests. Retracted, blood clot was a comparative material. Tissue factor activity in the parietal thrombus of the aneurysm was above threefold higher and antiheparin activity was nearly twice higher in comparison to the blood clot. Activity of plasminogen activators in the parietal thrombus was higher than in the blood clot. The parietal thrombus contained fourfold more of the plasminogen. Antiplasmin activity in the thrombus was above twofold lower than in the blood clot. High activity of the tissue factor and substances neutralizing heparin may intensify the thrombus growth. Yet the thrombotic tendency may be balanced by a high activity of plasminogen activators and plasminogen.

Cathepsin D and cathepsin L activities in aortic aneurysm wall and parietal thrombus.

Deterioration of the aortic wall resulting in formation of aneurysms may be caused by increased activity of metalloproteases and lysosomal proteases. The aim of this work was the evaluation of cathepsin D and cathepsin L activities, and activities of inhibitors of cysteine cathepsins in the wall of aortic aneurysms and in parietal thrombus. Aortic aneurysms were obtained during operation. Aortas taken from organ donors and blood clots were used as control material. Activities of cathepsin D and cathepsin L in the aortic aneurysm wall and parietal thrombus were higher than in the control groups. The aneurysm wall showed lower activity of inhibitors of cysteine proteases than the normal aorta. Parietal thrombus had a higher level of cysteine protease inhibitor activity than blood clot. Cathepsin D and cathepsin L present in the aneurysm wall and in the parietal thrombus filling the aneurysm may act on proteins determining elasticity and mechanical resistance of arteries.

Activities of proteases in parietal thrombus of aortic aneurysm.

Deterioration of the aortic wall resulting in formation of aneurysm may be evoked by increased activity of elastases, collagenases and lysosomal proteases. These enzymes come from macrophages and neutrophil granulocytes which are elements of the inflammatory reaction accompanying aneurysm. These cells may also come from parietal thrombus in the aneurysm lumen. The aim of this work was to determine activity of elastase, cathepsin G, collagenase-like Pz-peptidase and cathepsins A, B, C, D and E in the parietal thrombus of aortic aneurysm. The thrombus was obtained from the lumen of the aortic aneurysm of six patients during operation. Protease activities were determined using specific substrates at optimum pH. Retracted blood clot was a comparative material. The thrombus of aortic aneurysm showed two-five fold higher activity of elastases, collagenase-like Pz-peptidase and cathepsins A, D and G in comparison to the blood clot (P < 0.001). However, activity of cathepsins B, C and E in the thrombus was only slightly higher (P < 0.05). Prolonged effect of proteases coming from parietal thrombus on the aneurysm wall could evoke marked degradation of fibrillar proteins resulting in increase of aneurysm.

Endogenic non-enzymatic antioxidative system of polyester grafts during their healing.

OBJECTIVE: Non-enzymatic low-molecular antioxidants are one of the important mechanisms which protect cells against the toxic effect of oxygen. The aim of the present study was to determine the content of glutathione, glutathione reductase, and ascorbic acid in the principal layers of polyester grafts. INTERVENTIONS AND MEASURES: The experiments were carried out on 24 mongrel dogs, in which polyester double velour DALLON grafts were implanted. Seven days, 1, 4, and 12 months after the operation the grafts were excised. The following were determined: glutathione content by use of a GSH-400 system, glutathione reductase activity by the method of Langdon and Mize, and ascorbic acid content by the Kyaw method. RESULTS: It was found that the glutathione content in the graft neointima was 33% lower, in the graft neomedia higher during the first 4 months, in the neoadventitia 50% lower after 4 months than in the corresponding layers of the aorta (p < 0.01). The activity of glutathione reductase was significantly higher in all the graft layers during 12 months' observation than in the normal aorta layers. The ascorbic acid content of the graft layers was lowest 7 days after the implantation, and then in time increased so that 12 months after the operation it reaches its highest values. CONCLUSIONS: Our study shows that low non-enzymatic antioxidative potential is not capable of proteoting the newly forming graft layers, particularly the neointima, against oxygen toxicity. Thus, it would be beneficial to administer antioxidants (vitamin C, vitamin E, and N-acetylcysteine).

Activity and distribution of superoxide dismutase in the layers of polyester grafts.

The aim of the present study was to evaluate superoxide dismutase (Cu, Zn-SOD) activity in the principal layers of polyester grafts implanted into the abdominal aorta of dogs. The grafts were examined 7 days and 1, 4 and 12 months after the operation. It was found that SOD activity occurred in all polyester graft layers during the whole experiment. The neointima activity ws 1.5-fold lower during the 1st month; with the passage of time, it became 2-fold lower than in the normal aorta (p < 0.01). SOD activity in the medial and outer graft layers behaved similarly: it was lowest after 7 days, increased after 1 month and significantly decreased after 4 and 12 months (p < 0.01). Our study shows that the activity of SOD is low in polyester grafts and it can thus be inferred that protection against the superoxide anion is inadequate.

Activity of enzymes of various subcellular localisation in cytosol obtained after cell organelle precipitation at pH 5.0.

Acidification to pH 5.0 of various organ homogenates prepared in 0.25 M sucrose causes aggregation of cell organelles. Aggregated organelles are removed through standard centrifugation. Cytosol obtained reveals only slight activity of membrane and lysosomal enzymes. The cytosol is useful for evaluation of changes in enzyme distribution in cell.

Disturbances of hemostasis during declamping shock.

The aorta, above or below renal arteries was clamped for 60 minutes, in a canine model. The blood was taken for testing from above the aorta bifurcation before clamping, after 30 minutes of its duration, directly after declamping and every 30 minute during next 4 hours. Irrespective of clamping level, the platelet count, clot retraction and prothrombin consumption do not undergo significant changes. However, the activity of platelet factor 4 is increased. Prothrombin time, recalcination time, kaolin-kephalin time and the activities of factors V, VII, XI and XII do not differ as well. Thrombin time is prolonged and antithrombin III activity is reduced. Euglobulin fibrinolysis time undergoes prolongation and antiplasmin content is increased. The observed changes show a variable tendency, regardless of clamping level and increase with the passage of experiment time. An increase in the coagulation activity and a decrease in the fibrinolytic activity of the blood plasma may be a resultant of the changes. Finally it may promote thrombus formation and indicates the preventive use of heparin.

Hemostatic activity of organs in declamping shock.

The aim of the study was to determine the haemostatic components activity of organs in declamping shock. The abdominal aorta was cross-clamped below or above renal arteries. No significant changes in tromboplastic and antithrombin activities were found in the kidney, liver, lung, heart and skeletal muscle. Renal cortex and medulla as well as the lungs show higher plasminogen activator activity and considerably higher antiplasmin activity. Diminished fibrinolysis in the kidney and the lung may promote thrombotic complications.

Activity of membrane, cytosol and lysosome enzymes in organs and blood serum during declamping shock.

The aim of the study was to evaluate the enzyme activity of cellular membranes (GGT), cytosol (ALT, AST) and lysosome (AP, AcP) in the cytosol, whole homogenate and blood serum during declamping shock, following release of abdominal aorta cross-clamping. The aorta was clamped for 60 minutes. An increase in GGT, AP and AcP activities in the cytosol and whole homogenate of the renal cortex, renal medulla, liver, lung, heart and the skeletal muscle occurs after declamping. Rise in the enzymatic activity, especially of acid phosphatase is higher when the aorta above renal arteries was clamped. However, its activity in the blood serum remains unchanged. Alterations in the distribution and the activity of the studied enzymes may indicate that aortic clamping damages the endoplasmic reticulum and lysosomal membranes. Yet, cellular membranes preserve their structural and functional integrity.

Cathepsin D activity and protein degradation products in organs and blood during experimental declamping shock.

Aortic cross-clamping in dogs for 60 min causes an increase in cathepsin D activity in the kidney, liver, lung, heart, skeletal muscle and the blood serum. It causes no changes in the content of protein and its degradation products of the examined organs, apart from the lungs, where the above parameters are higher. The intensity of the observed changes in the kidney and other organs does not depend on the level of aortic cross-clamping (above or below renal arteries).

Collagen, elastin and glycosaminoglycans in aortic aneurysms.

The walls of human abdominal aortas and atherosclerosis-induced aneurysms contain similar amounts of collagen. The quantitative ratio between collagens of various types of this protein does not differ significantly either, whereas solubility of the collagen in aneurysmal wall and its susceptibility to the action of EDTA are distinctly decreased. In contrast with collagen, the amount of elastin in aneurysms is significantly lower. Total amount of glycosaminoglycans slightly decreased as compared with that of normal tissue, but the ratio of particular compounds varies. The percentage of chondroitin sulphate is increased and that of heparan sulphate significantly decreased. The significance of these changes in pathogenesis of aneurysms is discussed.

Surgical management of abdominal aortic aneurysms in Poland. A multi-centre study.

Abdominal aortic aneurysm resections were performed on 941 patients between 1987 and 1991 in nine selected university vascular units in Poland. The aim of the study was (1) to determine how grave the problem of abdominal aortic aneurysms is in the main vascular centres in our country, (2) to evaluate the methods of management, (3) to trace the most common postoperative complications, and (4) to estimate results. Hospital mortality rate for 730 elective and urgent resections was 8.2%. The emergency resection mortality rate for ruptured aneurysm was 60.2%. The most common postoperative general complications were: cardiac (178-18.9%), pulmonary (76-8.1%), renal failure (58-6.2%) and cerebrovascular accidents (23-2.4%). The postoperative local complications (113) occurred in 87 (9.2%) patients. The most common were: colon ischemia (22-3.5%), haemorrhage (30-3.2%), acute graft occlusion (22-2.3) and peripheral embolism (19-2%). Sixty-five patients required early reoperation undergoing a total of 74 additional operative procedures. The local complications occurring in analysed material significantly influenced the results. Mortality in reoperated patients was almost twice as high as among those not reoperated (p < 0.01). Analysis of the material revealed no differences in the obtained results of aneurysm surgery in the succeeding years of our study, when expecting improvement in the last years. The cause of this could be treatment of more high risk patients. The absolute number of patients with abdominal aortic aneurysms referred to the unit influenced results.(ABSTRACT TRUNCATED AT 250 WORDS)

[Thrombolytic therapy in arterial thrombosis producing acute ischemia of the lower limbs]. / Leczenie trombolityczne zakrzepicy tetnic powodujacej ostre niedokrwienie konczyn dolnych.

Efficiency of the thrombolytic therapy in the acute arterial thrombosis (producing an acute ischemia of the lower limbs) with streptokinase has been assessed in 35 patients treated in the selected departments of vascular surgery in Poland. Complete recovery has been noted in 9 patients (25.7%) in whom limb functioning with detectable peripheral pulse have been restored. An improvement has been achieved in 12 (34.3%) patients and moderate result in 4 (11.4%) patients. The limb has been amputated in 7 (20%) patients, and 3 patients (8.6%) died. Similar results have been observed in case of ischemia of duration period below 12 hours, between 12 and 24 hours, and between 24 and 72 hours. The results have been worse when thrombolytic therapy was introduced after 72 hours.

Subcutaneous low molecular weight heparin versus subcutaneous unfractionated heparin in the treatment of deep vein thrombosis: a Polish multicenter trial.

In a prospective multicenter trial, 149 consecutive patients with phlebographically proven proximal and/or distal deep vein thrombosis of the leg were randomly allocated to receive subcutaneously for 10 days either low molecular weight heparin CY 216 (Fraxiparine) in a fixed dose or unfractionated heparin (UFH) in doses adjusted according to the activated partial thromboplastin time. Pre- and post-treatment phlebograms were assessed blindly using the Arnesen's score system in 134 patients available for analysis of the treatment efficacy. The mean phlebographic score after 10 days of treatment was significantly decreased in both groups (p less than 0.001) in comparison with the baseline score but the difference in score changes between the two groups was not statistically significant. There was an improvement in 45/68 patients (66%) in the Fraxiparine group and in 32/66 patients (48%) in the UFH group, and an increase in the thrombus size in 10/68 (15%) and 12/66 (18%), respectively. One symptomatic non-fatal pulmonary embolism and one major bleeding episode were observed in the UFH group. During a follow-up period of 3 months, two rethromboses had occurred in the UFH group and none in the Fraxiparine group. It is concluded that subcutaneous fixed dose Fraxiparine is safe and at least as effective as subcutaneous adjusted UFH in the treatment of deep vein thrombosis.

[Late results of surgical and conservative treatment for atheromatous ischemia of the lower limb in young patients]. / Odlegle wyniki leczenia operacyjnego i zachowawczego miazdzycowego niedokrwienia konczyn dolnych u mlodych chorych.

The study was carried out within a multicenter program. Hundred fifty four patients under 40 years were treated (73 conservatively, and 81 surgically) for the atheromatous ischemia of the lower limbs in 14 Departments of Vascular Surgery in Poland within 5 years. The results of the treatment were evaluated according to the site of atheromatous lesions, type of surgery, and mainly according to the progress in pathologic process expressed by the degree of limb ischemia. It was found that surgery performed in the II period of the disease produces the best results. Surgery produces positively better results than conservative treatment in patients with the II period of the disease whereas both surgical and conservative therapy are ineffective in the III and IV degrees of ischemia. Sympathectomy may be effective in the occlusion of crural arteries even of the IV degree ischemia. In case of the II degree ischemia better results are produced by the operation of aorto-iliaco-femoral segment (transplantation or thrombendarterectomy) than that involving distal segment (sympathectomy) whereas the results of conservative therapy are better in peripheral and iliaco-femoral occlusion than those in aortofemoral and multisegmental arterial occlusion. An opinion of several authors on the specificity of atheromatous ischemia of the lower limbs in young patients was not confirmed.

[Results of surgical and conservative treatment for multi-level atheromatous arterial occlusion of the lower limb after five years]. / Wyniki leczenia operacyjnego i zachowawczego wielopoziomowej miazdzycowej niedroznosci tetnic konczyn dolnych po 5 latach.

After 5 years of observation, materials of 239 patients treated operatively and 96 patients treated conservatively because of multisegmental arterial occlusion of lower limbs were obtained within the framework of multi-central programme of investigation. The results of the treatment with these methods have been evaluated according to the site of the atheromatous changes and the degree of ischemia of lower limbs. It has been ascertained, that after operative therapy, the percentage of good results and the percentage of death in the case of occlusion comprising the aorto-ilio-femoral segment is higher than in the case of occlusion of femoro-popliteal and peripheral segments, whereas in the case of conservative therapy, the situation is reverse. The results of therapy (operative and conservative) of multilevel arterial occlusion, in all kinds of location, depend upon blood supply in the limbs. The results are best (the highest percentage of good results and without improvement, the least number of amputation and death) in the II period of disease and they become worse when the degree of ischemia increases. It appears that the operative therapy is less effective than the conservative therapy in the case of atheromatous multilevel changes manifesting clinically in the form of intermittent claudication, whereas in the case of the IV degree of ischemia, only the operation can save the limb or even the patient's life.

[Effect of different vascular prosthesis materials on blood platelets, blood clotting and fibrinolysis]. / Wplyw tworzyw róznych typów protez naczyniowych na plytki krwi, uklad krzepniecia i fibrynolize.

Studies were performed on Dacron vascular prostheses (USA), Gore-Tex (Germany), polyester prostheses (Czechoslovakia), Lawsan (Russia), as well as on DALLON-standard and DALLON-double velour prostheses (Poland), non-impregnated or impregnated with collagen, with heparin and albumin, with antithrombotic and antibacterial preparation, and with antibacterial preparation. In vitro, all the materials of vascular prostheses cause an adhesion of platelets in different degree, increase the availability of platelet factor 3, release platelet factor 4, reduce the blood clot retraction, shorten clotting time of the whole blood as well as recalcination time of intact plasma and increase the prothrombin consumption. None of the materials induced platelet aggregation nor influenced the activity of fibrinolytic system. Prostheses impregnated with collagen or with heparin and albumin were the most thrombogenic. Those impregnated with antibacterial preparation or with antibacterial and antithrombotic preparations, and Gore-Tex prostheses showed the lowest thrombogenicity. Thrombogenicity of vascular prostheses not only depends on chemical structure of the material, but on the method of fibre manufacturing by individual producers as well.