Bilateral catheter-directed thrombolysis in a patient with deep venous thrombosis caused by a hypoplastic inferior vena cava.

INTRODUCTION: Deep venous thrombosis treatment using catheter-directed thrombolysis is advocated over systemic thrombolysis because it reduces bleeding complications. With the development of a catheter that combines ultrasound vibrations and the local delivering of thrombolytics, new and safer treatments appear that are suitable for more complex problems. REPORT: An adolescent male presented with bilateral iliofemoral thrombosis based on a hypoplastic inferior vena cava that had existed for more than two weeks. He was successfully treated by bilateral ultrasound-accelerated catheter-directed thrombolysis using EkoSonic® (Small Vessel) Endovascular System (EKOS) and stenting of the inferior vena cava. After eight months of follow-up, the inferior vena cava is still patent. CONCLUSION: EKOS thrombolysis of longer existing bilateral deep venous thrombosis in the central venous system is a successful treatment modality in congenital inferior vena cava anomalies.

Long-term outcome of equestrian injuries in children.

PURPOSE: To investigate the possible development of long-term disabilities arising from paediatric equestrian injuries. METHOD: All patients, aged 17 years or younger, treated in a hospital setting because of an equestrian injury during a five-year period received a questionnaire. A reference population and healthy friends served as controls. RESULTS: Four years post-injury, 41 of the 100 respondents still experienced disabilities following the injury. The median Injury Severity Score was 4. Absenteeism from school lasted 2 weeks, and from horse riding, 4 months. Compared to the reference population, the results of the Child Health Questionnaire were poorer considering most of its subscales. In comparison with the friends, the patients only scored lower on 'physical functioning'. The risk factors concerning poor long-term outcomes were being an advanced rider, sustaining injuries other than fractures of the extremities or sustaining subsequent injuries following the riding accident. CONCLUSIONS: Although equestrian injuries in children are minor to moderate in their severity, these injuries are significant considering that a large proportion of patients experience long-term disabilities.

Assessment of coronary angiograms prior to and after treatment with abciximab, and the outcome of angioplasty in refractory unstable angina patients. Angiographic results from the CAPTURE trial.

BACKGROUND: The CAPTURE study (c 7E3 A nti P latelet T herapy in U nstable Re fractory angina) was designed to assess outcome in patients with refractory angina undergoing angioplasty, receiving either abciximab or placebo. METHODS: One thousand two hundred and sixty-five patients with refractory unstable angina, defined as recurrent myocardial ischaemia despite medical treatment including heparin and nitrates were enrolled. After angiography, patients received an infusion of abciximab or placebo over 18-24 h preceding angioplasty, continuing until 1 h after the procedure. In 1197 patients undergoing angioplasty the angiographic committee centrally reviewed the baseline as well as the procedural angiograms. Coronary flow and lesion characteristics were assessed in the baseline angiogram as well as before intervention. Angiographic outcome, reason for failure as well as complications were assessed after angioplasty. RESULTS: At 30 days follow-up, patients receiving abciximab (n=595) compared with placebo (n=602) had a 30% reduction in the composite primary end-point death, myocardial infarction or urgent (re)intervention: 10.8% vs 15.4% (P=0.017). Baseline demographics were identical in the angiogram available group compared with the total study group. At 30 days, the non-angiogram available patients showed a higher incidence of events compared to those in whom the angiogram was reviewed: 19.4 vs 13.1% (P=ns). Lesion characteristics and coronary flow were not different at baseline between the placebo and abciximab groups. A primary end-point was reached in 9.6% of both placebo and abciximab patients with type A or B(1)lesions, in 17.0% vs 12.0% with type B(2)lesions, and in 19.1% vs 11.5% with type >B(2)or C lesions. Sixty-one percent of placebo and abciximab patients had TIMI 3 flow at baseline angiography. Pre-angioplasty TIMI 3 flow was observed in 69% and 72% respectively. The thrombus was resolved between the angiograms in 22% and 43% respectively, in the placebo and abciximab groups (P=0. 033). Angiographic success of the procedure was achieved in 88% and 94% in the placebo and abciximab patients, respectively (P<0.001). Stents were implanted in the ischaemia-related artery in 56 and 60 patients, respectively. However, failure of the stent procedure was more frequent in the placebo group than in the abciximab group, nine vs no patients (P=0.003). CONCLUSION: More frequent thrombus resolution was observed and a higher angiographic success rate was achieved in patients treated with abciximab before and during angioplasty compared with placebo. Patients with complex lesions as the underlying pathology reached fewer end-points if treated with abciximab before and during angioplasty.

Minimal myocardial damage during coronary intervention is associated with impaired outcome.

AIMS: Studies on the glycoprotein IIb-IIIa receptor blocker abciximab in patients undergoing percutaneous coronary intervention consistently show a reduction in procedure-related myocardial infarction. Some such infarcts are characterized by elevated creatine kinase or creatine kinase-MB, without apparent clinical symptoms. The clinical relevance of such 'creatine kinase leaks' has been questioned. Therefore we investigated the relationship between post-procedural creatine kinase-MB elevation and outcome at the 6 month follow-up. METHODS AND RESULTS: Creatine kinase-MB, or total creatine kinase values were analysed in 5025 out of 6156 patients enrolled in the CAPTURE, EPIC and EPILOG studies. A consistent gradual increase in 6 month mortality was observed as creatine kinase-MB or creatine kinase levels increased: 1.1%, 2.1%, 1.8%, 3. 6% and 6.7% for creatine-MB or creatine ratios (relative to upper limit of normal) <1, 1-3, 3-5, 5-10 and >/=10, respectively. Also the incidence of death or (recurrent) myocardial infarction was related to creatine kinase-MB or creatine kinase ratios. Subsequent revascularization was not related to periprocedural myocardial infarction. By multivariable analysis, correcting for clinical and angiographic characteristics, mortality at 6 months was related to the enzyme (creatine kinase, creatine kinase-MB) ratio, a history of heart failure and age. The combined end-point of death and myocardial infarction was also related to these factors, as well as to a history of bypass surgery and unstable angina. CONCLUSION: Modest elevation of cardiac enzymes (creatine kinase-MB, creatine kinase) after percutaneous coronary intervention is associated with an increased risk of mortality and reinfarction during the 6 month follow-up. Measures to reduce such periprocedural infarcts are warranted.

Benefit of abciximab in patients with refractory unstable angina in relation to serum troponin T levels. c7E3 Fab Antiplatelet Therapy in Unstable Refractory Angina (CAPTURE) Study Investigators.

BACKGROUND: In patients with refractory unstable angina, the platelet glycoprotein IIb/IIIa-receptor antibody abciximab reduces the incidence of cardiac events before and during coronary angioplasty. We investigated whether serum troponin T levels identify patients most likely to benefit from therapy with this drug. METHODS: Among 1265 patients with unstable angina who were enrolled in the c7E3 Fab Antiplatelet Therapy in Unstable Refractory Angina (CAPTURE) trial, serum samples drawn at the time of randomization to abciximab or placebo were available from 890 patients; we used these samples for the determination of troponin T and creatine kinase MB levels. Patients with postinfarction angina were not included. RESULTS: Serum troponin T levels at the time of study entry were elevated (above 0.1 ng per milliliter) in 275 patients (30.9 percent). Among patients receiving placebo, the risk of death or nonfatal myocardial infarction was related to troponin T levels. The six-month cumulative event rate was 23.9 percent among patients with elevated troponin T levels, as compared with 7.5 percent among patients without elevated troponin T levels (P<0.001). Among patients treated with abciximab, the respective six-month event rates were 9.5 percent for patients with elevated troponin T levels and 9.4 percent for those without elevated levels. As compared with placebo, the relative risk of death or nonfatal myocardial infarction associated with treatment with abciximab in patients with elevated troponin T levels was 0.32 (95 percent confidence interval, 0.14 to 0.62; P=0.002). The lower event rates in patients receiving abciximab were attributable to a reduction in the rate of myocardial infarction (odds ratio, 0.23; 95 percent confidence interval, 0.12 to 0.49; P<0.001). In patients without elevated troponin T levels, there was no benefit of treatment with respect to the relative risk of death or myocardial infarction at six months (odds ratio, 1.26; 95 percent confidence interval, 0.74 to 2.31; P=0.47). CONCLUSIONS: The serum troponin T level, which is considered to be a surrogate marker for thrombus formation, identifies a high-risk subgroup of patients with refractory unstable angina suitable for coronary angioplasty who will particularly benefit from antiplatelet treatment with abciximab.

Numerical simulation of blood flow in an artery with two successive bends.

Blood flow in an artery with two successive bends is simulated by a finite-element computation of steady flow of a Newtonian viscous fluid through a rigid tube having the same shape as a specific part of the femoral artery. Notwithstanding the fact that the bends in the model geometry are rather gentle, the axial and secondary flow patterns, computed for a range of values of the Reynolds number Re, show strong and complicated three-dimensional flow effects. In particular, the flow pattern in the second bend for relatively small values of Re (Re < 240) turns out to be drastically different from that for larger Re-values.

Characterization of reactivity of monoclonal autoantibodies with renal antigens in experimental lupus nephritis.

Mice with chronic graft-versus-host disease (GvHD), induced by injection of DBA/2 lymphocytes into (C57BL10*DBA/2)F1 hybrids, develop a lupus-like syndrome with immune complex glomerulonephritis. Circulating autoantibodies are reactive with various self-antigens, including DNA, renal tubular epithelium (RTE), and laminin-1. To elucidate the reactivity of autoantibodies with renal antigens in experimental lupus nephritis further, the reactivity of the autoantibodies was studied in more detail by generating hybridomas from GvHD spleen cells. Hybridomas were selected for reactivity with RTE and laminin-1 coated on nitrocellulose sheets. Four stable clones were obtained (GV1-GV4). Monoclonal antibody (mAb) GV1 showed no reactivity on kidney sections, while GV2 stained the brush border of proximal tubular epithelial cells. Both GV1 and GV2 reacted only with RTE in ELISA. GV3 showed a nuclear staining pattern, while GV4 stained matrix structures on F1 kidney sections. GV3 and GV4 both reacted with RTE, laminin-1, ssDNA, and dsDNA in ELISA. Growth of hybridomas in mice, but not passive transfer of the mAbs, led to glomerular Ig binding for mAbs GV3 and GV4 without development of proteinuria. Our results show that in addition to anti-nuclear autoantibodies cross-reactive with renal antigens, autoantibodies reactive with renal antigens and not with DNA are generated during chronic GvHD. Based on these results, combined with those of earlier experiments, we conclude that a combination of autoantibodies against multiple epitopes is necessary for the induction of glomerular damage in this model for lupus nephritis.