Thrombosis of the muscular calf veins--reference to a syndrome which receives little attention.

BACKGROUND: Thrombosis of the soleal and gastrocnemial veins seldom receive very much attention. It is thought that they are frequently the starting point for deep vein thrombosis of the lower extremity. PATIENTS AND METHODS: 125 patients with clinically suspected deep vein thrombosis of the leg were examined by means of duplex sonography and phlebography. The ultrasound examination was performed on the lower limb in the form of a compression sonography. RESULTS: From 137 legs examined, a total of 82 cases of deep vein thrombosis were diagnosed. Sonographically and/or phlebographically, the soleal and/or gastrocnemial veins were found to be involved in 65 cases of thrombosis, i.e. 79% of all thrombosis. 25% of all cases of deep vein thrombosis of the leg were isolated muscular vein thrombosis. Pain in the calf while walking, similar to muscular soreness after exertion, was typical of the isolated muscular vein thrombosis. The muscular veins were involved in all the deep vein thrombosis of the leg of the 3- and 4-layer type. Diagnosis of soleal and gastrocnemial vein thrombosis is quite possible by means of sonography and phlebography. The sensitivity and specificity of the compression sonography were 88% and 95% respectively, compared to the phlebography. CONCLUSION: In patients suffering from pain in the calf, the soleal and gastrocnemial veins should be carefully included in the sonographic or phlebographic assessment. Due to the risk of deep vein thrombosis, isolated muscular vein thrombosis should receive treatment appropriate for a deep vein thrombosis of the calf, and its development be checked.

[The value of color-coded duplex ultrasound in the immediate postoperative phase of carotid artery reconstruction]. / Zum Stellenwert der farbkodierten Duplex-Sonographie in der unmittelbar postoperativen Phase einer Karotisrekonstruktion.

Diagnostic value of color-coded duplex sonography within the first hours following carotid artery reconstruction was investigated. We examined 15 out of 290 patients who developed neurologic symptoms after carotid endarterectomy. During the early postoperative period color-coded duplex sonography was associated with some problems. The investigation at this time was characterized by poor quality of B mode and color Doppler. It may be caused by deposition of air or bleeding. Differentiation of internal and external carotid arteries was difficult. When Doppler sonography of the reconstructed carotid artery was additionally performed, more accurate information was obtained. A normal reconstructed internal carotid artery was found in 8 patients, whereas 5 patients showed pathologic results (3 stenoses, 1 total occlusion, 1 embolisation). In patients with pathologic changes reoperation was immediately performed. Results of ultrasound investigations were proved by intraoperative findings. In 2 patients examination of the reconstructed internal carotid artery was impossible even by the combination of duplex and Doppler sonography. We conclude that color-coded duplex sonography in combination with Doppler sonography is a valuable method for investigations in the early postoperative period following carotid artery reconstruction.

[Evaluating the extracranial cerebral arteries with ultrasound angiography]. / Beurteilung der extrakraniellen Hirnarterien mit der Ultraschall-Angiographie.

AIM: Ultrasound angiography is a new method of colour-coded vessel imaging. The present study aimed at giving further information on its clinical utility in neurosonology. METHOD: The extracranial arteries of 53 patients and 5 normal persons were investigated by ultrasound angiography in comparison with colour-coded duplex sonography. RESULTS: We found a sharper imaging of stenoses and plaques by ultrasound angiography compared with colour Doppler. The imaging of the vessels can be achieved more continuously, avoiding dropouts of the colour. Small vessels and branches can be detected more reality. CONCLUSION: Ultrasound angiography represents a valuable additional imaging technique to colour-coded duplex sonography, providing further information, especially with regard to the border of plaques and stenoses.

[Possibilities and limits of a new color technique: ultrasound angiography--results of the "Heidelberg Round Table Discussion"]. / Möglichkeiten und Grenzen einer neuen Farbtechnik: die Ultraschall-Angiographie--Ergebnisse des "Heidelberger Rundtischgespräches."

Sonographic diagnostics has been essentially enlarged by blood flow measurements with the color Doppler technique. Nevertheless, the method has certain limitations, especially when employed to visualize extremely slow blood flow velocities, which occur e.g. in malignant tumors due to neovascularization. Recently, a new technique, the so-called angio-color procedure, has been presented, which is supposed to overcome the above-mentioned limitations. The way of coding the signal differs considerably from that in conventional color Doppler: The amplitude is color coded, not the frequency deviations. Results and first experiences with the new procedure in various domains were discussed at a 'Heidelberg Round Table' and are summarized in the present article. In the obstetrics/gynecology there are clear advantages in the representation of blood flow in the placenta. In eutrophic fetuses a blood flow over the entire placental breadth was detected, in dystrophic fetuses, however, only on the margins of the placenta. Conventional color Doppler could not visualize blood flow in the placenta at all. Blood flow assessment in the fetal organs also provided different results with the two procedures: the angio-color method showed color pixels even in the peripheral areas. In 8 malignant breast tumors the same observation was made, the angio-color procedure seemed to visualize more color pixels. In 4 of 6 benign lesions blood flow could be measured with the traditional color Doppler, but in 5 of 6 patients with the angio-color Doppler. This was also observed in ovarian tumors. Angio-color representation of renal transplants with normal function resulted in blood flow information reaching deep into the renal capsule, whereas in cases of renal transplants with impaired function a clearly reduced perfusion was visualized. These differences were not so evident with the conventional Doppler method. In lymph node diagnosis, too, marked differences between malignant and reactive lymph nodes could be visualized. In the diagnosis of arteriosclerotic plaques, blood flow in the residual lumen could also be detected more exactly with the angio-color technique. Color representation of liver tumors also showed a higher color signal density with ultrasound angiography. In summary, ultrasound angiography can provide additional information in the color representation of vessels with slow flow velocities. However, an obvious problem is the unability to quantify detected low blood flow. The new procedure will not replace but usefully complete the established sonographic techniques.

[Reconstruction of brain-supplying arteries with bilateral monitoring by transcranial Doppler ultrasound--new aspects for technical surgical procedures]. / Rekonstruktion der hirnversorgenden Arterien unter bilateralem Monitoring mit der transkraniellen Doppler-Sonographie--neue Aspekte für das operationstechnische Vorgehen.

From January to June 1994 reconstruction of 61 internal carotid arteries (ICA) with cerebral monitoring using bilateral transcranial Doppler sonography in the Clinic of Vascular Surgery Charité was performed. Recording of the maximal mean blood flow velocity in both middle cerebral arteries (MCA) was performed intraoperatively. After clamping of ICA flow velocity in the ipsilateral MCA decreased immediately but recovered within short time in 60% of our patients (Vmean > 25 cm/s). Based on the reaction of the contralateral MCA 3 types were differentiated: 1) Vmean of the contralateral side changed contrary to the ipsilateral side (compensation, "scissors type"). 2) The contralateral side did not react ("indifferent type"). 3) The contralateral side changed parallel to the ipsilateral side ("parallel type"). In 62% of our patients the operative strategy was influenced by transcranial Doppler monitoring: in 35% of cases the operative reconstruction was performed without intraluminal shunting, in 19% of cases the position of the intraluminal shunt was corrected, in 8% of cases the blood pressure was increased. Doppler signals due to emboli were registered in 43% of our patients. These patients did not show any new neurologic signs and symptoms. In one patient who developed a neurological deficit during the postoperative phase, emboli signals were recorded during a period of 30 minutes. Bilateral transcranial Doppler monitoring, especially in patients with contralateral high-grade stenoses or occlusions of the ICA, is a useful method for intraoperative cerebral monitoring. We recommend its application on a wide scale.

[Catheter-induced thromboses--duplex ultrasound studies of incidence and extent]. / Katheterinduzierte Thrombosen--duplexonographische Untersuchungen zu Häufigkeit und Ausmass.

The aim of the study was to detect the frequency and the extension of thrombosis caused by central venous catheters by means of Doppler-duplex ultrasound. 36 patients were examined. The visualization rate of catheters in jugular (91%) and femoral (62%) veins was excellent. In contrast, catheters in the subclavian vein could be detected only in 33 per cent of all cases. As a result the overall patency rate of catheters was only 37 per cent after a period between 8 hours and 60 days (12.2 +/- 11.3 days) following the introduction. There was no significant relation between the type of catheter, the management with central venous catheters and the rate of thrombosis.

[Initial experiences with ultrasound angiography in the area of extracranial and peripheral arteries]. / Erste Erfahrungen mit der Ultraschall-Angiographie im Bereich der extrakraniellen und extremitätenversorgenden Arterien.

First experience with ultrasound angiography of extracranial and peripheral arteries in 20 patients is reported. Ultrasound angiography is a new method of color-coded vessel imaging. It is based on signal processing of the blood flow amplitudes. Color imaging of echo signals by ultrasound angiography is independent of the direction and velocity of blood flow and of the angle of ultrasound beam. Aliasing and changes of colors due to changes of direction do not exist. We found a sharper imaging of the vessel lumen and the vessel wall compared with color Doppler. Imaging of vessel branches and small vessels is even better. Documentation of vessels by ultrasound angiography is similar to angiography and can be obtained convincingly. Application of this method in addition to color-coded duplex sonography is recommended.

[Importance of PQ time in the evaluation of bifascicular block]. / Zur Bedeutung der PQ-Zeit bei der Beurteilung bifaszikulärer Blockbilder.

In 103 patients with bifascicular block was tested by means of the His bundle electrography, whether with the help of the PQ-time an indirect estimation of the conduction capacity of the still conducting fascicle (HV-interval) is possible. In 70% of the cases with bifascicular blocking and AV-block of first degree the HV-interval was prolonged. However, also 45% of the patients with bifascicular block showed a prolonged HV-interval despite normal PQ-time. Of 21 patients with syncopes due to an intermitting trifascicular block 10 had a normal PQ-time in phases of the transduction. Thus a normal PQ-time in patients with bifascicular block is no guarantee for a good transduction via the still conducting fascicle. If in patients with bifascicular block additionally an AV-block of first degree is existing, the place of the primary retardation of the conduction should more exactly be analysed. For this purpose offer themselves an atropine test or the His bundle electrography.