[Frequency, Cause, and Awareness of Pulmonary Embolism in Oncologic Patients]. / Die Lungenarterienembolie bei onkologischen Erkrankungen: Häufigkeit, Ursachen und Wahrnehmung.

The frequency of pulmonary embolism (PE) in oncologic patients ranges from 1.1 % to 7.3 % depending on whether not only symptomatic findings but also incidental and initially overseen events are considered. The frequency of PE is tumor-specific. Most frequently PE occurs in patients with malignancy of the ovary (25 %), pancreas, brain, uterus, and multiple myeloma. Most rarely is PE found in patients with malignancy of the testis (< 1 %).The tumor-specific frequency shows that the association of malignancy and PE is not equally true for alle malignancies. A number of arguments that support the above association are also valid in non-oncologic patients.The awareness of the diagnosing radiologist and the thrombus mass decide whether or not an unexpected PE is detected. An increased awareness is suggested in patients with malignancies with high PE frequency and in patients with advanced oncologic disease.

[Chronic venous insufficiency]. / Chronische venöse Insuffizienz.

Chronic venous insufficiency is an advanced chronic venous disease, which as a result of venous hypertension leads to specific skin or subcutaneous tissue changes on the lower extremities. The descriptive CEAP classification enables a standardized classification of chronic venous disorders. Color-coded duplex ultrasonography is the center of diagnostic measures, which enable functional and morphological conclusions regarding specific venous changes and possible differential diagnoses. Chronic venous insufficiency therapy targets the reduction or elimination of the underlying venous hypertension. Due to their high prevalence and age-associated increase, chronic venous diseases represent a problem affecting the quality of life of persons concerned and representing a cost-intensive problem for public health care.

Long-term outcome of patients with mild intermittent claudication under secondary prevention.

BACKGROUND: The known natural history of peripheral arterial disease (PAD) is determined by the generalization of atherosclerosis with resulting high cardiovascular and cerebrovascular morbidity and mortality. The aim of this prospective study was to record all vascular and non-vascular events in patients with mild intermittent claudication (IC) undergoing secondary preventive measures in a 10-year follow-up and to determine the time-points at which systemic localizations of atherosclerotic events develop. PATIENTS AND METHODS: Patients who originally had an isolated Fontaine stage IIa PAD were included in the follow-up which involved assessments carried out on an annual basis. The incidence and timepoints of vascular (i.e., myocardial infarction, stroke, critical limb ischemia, vascular death), and nonvascular events (i.e., cancer, non vascular death) were recorded and compared with the known natural history. RESULTS: 534 events (vascular: 433) concerning 109 claudicants (M/F: 88/21; 60.8 +/- 8.8 years; ABI 0.66 +/- 0.11) were recorded over an average follow-up period of 104 months. 25.7% of the claudicants died, 39% due to vascular events, 36% due to cancer disease and 25% due to other events. A deterioration of PAD (n = 108) was the most frequent event after 20 months, followed by angina pectoris (n = 41) and cancer diseases (n = 20) after 42 and 45 months, stroke (n = 19) after 58 months, myocardial infarction (n = 12) after 63 months, and finally critical limb ischemia (n = 27) and amputations (n = 10) after 80 and 114 months (median). 111 revascularizations were carried out. 62.3% of the claudicants developed a polyvascular disease, with 20% in a trivascular territory. CONCLUSIONS: A high vascular comorbidity also develops under secondary prevention as an expression of the continuing generalization of the atherosclerotic process in PAD. The causes for death are determined both by the vascular and the tumor related comorbidity.

[Markers predicting progression of disease in PAD: Which of them are both relevant to clinical practice and economically justifiable?]. / Prädiktive Marker der Krankheitsprogression bei pAVK. Welche sind praxisrelevant und ökonomisch vertretbar?

The high cardiovascular morbidity and mortality on peripheral arterial disease (PAD) are attributable to the pronounced tendency to generalization of the atherosclerotic process, the systemic progression of atherosclerosis. The crucial objective in management of a PAD consists in preventing systemic progression. The prognosis can be improved by early diagnosis and early prediction of individual risk with subsequent risk-adapted prevention and causal therapy. Early diagnosis and risk prediction are measures that are already part of the repertory of the general practitioner. Practicable and economically justifiable parameters that nevertheless have a high predictive value are therefore required to stratify individual risk. The vascular indicators ankle-arm index and the localization of the PAD as well as the classical cardiovascular risk factors including homocysteine are suitable. Weighting of these parameters in a multivariable risk score enable the population with the highest risk of early generalization of atherosclerosis to be identified in PAD.

Prevention of deep-vein thrombosis after total hip and knee replacement. Low-molecular-weight heparin in combination with intermittent pneumatic compression.

After total hip (THR) or knee replacement (TKR), there is still an appreciable risk of developing deep-vein thrombosis despite prophylaxis with low-molecular-weight heparin (LMWH). In a prospective, randomised study we examined the efficacy of LMWH in combination with intermittent pneumatic compression in patients undergoing primary unilateral THR or TKR. We administered 40 mg of enoxaparin daily to 131 patients combined with either the use of intermittent pneumatic compression or the wearing of graduated compression stockings. Compression ultrasonography showed no evidence of thrombosis after LMWH and intermittent pneumatic compression. In the group with LMWH and compression stockings the prevalence of thrombosis was 28.6% (40% after TKR, 14% after THR). This difference was significant (p < 0.0001). In the early post-operative phase after THR and TKR, combined prophylaxis with LMWH and intermittent pneumatic compression is more effective than LMWH used with graduated compression stockings.

Hyperhomocysteinemia: marker of systemic atherosclerosis in peripheral arterial disease.

AIM: Patients suffering from peripheral arterial disease (PAD) are increasingly described as having hyperhomocysteinemia more than in patients with coronary artery or cerebrovascular disease. Cases of symptomatic PAD usually present with associated coronary artery or cerebrovascular disease and renal artery disease. It can thus be postulated that multilocular atherosclerosis is linked to hyperhomocysteinemia and that the extent of atherosclerosis has a possible correlation with homocysteine concentrations. The aim of this study was to ascertain whether fasting total homocysteine concentrations in patients with PAD are associated with the extent and the localization of systemic atherosclerosis in cerebrovascular, coronary and/or renal vascular zones. METHODS: A total of 183 patients with PAD, Fontaine stages II-IV, were divided into 2 groups: Group A contained patients with isolated PAD (n=98) and Group B patients with systemic atherosclerosis in PAD (n=85). Characterization of vascular disease in various vascular zones was indication-adapted using non-invasive and/or invasive METHODS: Patients with renal insufficiency were excluded from the study. RESULTS: Homocysteine concentrations were significantly lower in patients with isolated PAD than in patients with additional systemic atherosclerosis (10.1+/-4.4 vs 16.7+/-7.04 micromol/l, p<0.0001). There were no differences in localization or extent of concomitant systemic atherosclerosis. Logistic regression analysis indicated that elevated plasma homocysteine and decreasing ABPI served independently as significant risk indicators for systemic atherosclerosis in patients with PAD (p<0.0001). CONCLUSION: Hyperhomocysteinemia is a precursoral marker of systemic atherosclerosis and thus a prognostic indicator of cardiovascular morbidity and mortality in PAD.

[Vascular complications in thoracic outlet syndrome: combined transaxillary revascularization and rib resection]. / Vasculäre Komplikationen bei Thoracic-outlet-Syndrom: kombinierte transaxilläre Revascularisation und Rippenresektion.

Based on two patients with vascular complications in thoracic outlet-syndrome, the anatomic and pathophysiologic principles prior to surgery are discussed. Causative therapy including rib resection and elimination of the embolic source in the subclavian artery is often supplemented by peripheral revascularization with bypass, lysis and/or sympathectomy. The transaxillary approach seems to be optimal, combining minimally invasive principles with a long exposure of the subclavian artery from segment 3 to the proximal axillary artery.

Prevalence of deep venous anomalies in congenital vascular malformations of venous predominance.

PURPOSE: The overall incidence of congenital vascular malformations in the general population is 1.5%. Approximately two thirds of them are malformations of venous predominance. Abnormalities of the deep venous trunks have been observed in association with large superficial compensatory varices in these type of malformations. Knowledge of the integrity of the deep venous system is important in their management because excision of the enlarged superficial veins may be deleterious if there is aplasia or hypoplasia of the deep venous trunks. The objective was to investigate the prevalence and nature of deep venous anomalies that occur in patients with congenital vascular malformations of venous predominance both in our series and in the series from the medical literature. METHODS: From the last 35 years of medical literature, we reviewed seven series of congenital vascular malformations that provided pertinent information on the subject of our study. We also reviewed our own series of 392 patients with congenital vascular malformations studied at Children's Hospital of Mexico City (1963-1983; n = 223 children) and at Walter Reed Army and National Naval Medical Centers (1984-1998; n = 169 children). Of 392 patients, 257 (65.5%) had malformations of venous predominance; these were the subject of our analysis. Prevalence of the following deep venous anomalies was recorded: phlebectasia, aplasia or hypoplasia of venous trunks, aneurysms, and avalvulia. Diagnosis was made by one or more of the following methods: Doppler scanning, duplex scanning, plethysmography, computerized tomography, magnetic resonance imaging, and angiography. RESULTS: At least one anomaly of the deep venous system was present in 47% of the congenital vascular malformations of venous predominance reviewed. Phlebectasia was recorded in 36% of the cases, and aplasia or hypoplasia of deep venous trunks was observed in 8% of the cases. Venous aneurysms also were present in 8% of the cases; avalvulia was recorded in 7% of the cases. CONCLUSION: Anomalies of the deep venous system occur in almost one half of congenital vascular malformations of venous predominance. The most common is the relatively innocuous phlebectasias that occur in over one third of cases. Aplasia/hypoplasia, venous aneurysms, and avalvulia were less frequent, each less than 10%; but failure to detect the latter three anomalies may lead to serious therapeutic errors.

Angiotensin-converting enzyme gene insertion/deletion polymorphism and carotid artery wall thickness in patients with peripheral arterial occlusive disease.

BACKGROUND: It has been suggested that the deletion polymorphism of the angiotensin converting enzyme (ACE) gene is linked to a high risk of cardiovascular disease. The relationship between the insertion/deletion (I/D) polymorphism of the ACE gene and the carotid intima-media thickness in patients with peripheral arterial occlusive disease is unknown. We tested the hypothesis that the early progression of atherosclerosis in the extracranial carotid arteries in patients with peripheral arterial disease is associated with a genetic predisposition. METHODS: This prospective trial included 98 patients who only had manifestations of arteriosclerotic disease in peripheral arterial vascular regions of the lower extremities (stable stage II PAOD). Maximal common carotid intima-media thickness (mIMT) was measured using high resolution B-mode ultrasonography. Determinations of ACE gene polymorphism were made using a polymerase chain reaction technique. Multivariate regression analysis was performed to assess the influence of ACE genotypes, ACE activity and vascular risk factors on intima-media thickness. RESULTS: There was no significant association between intima-media thickness and ACE gene polymorphism. History of symptomatic peripheral arterial disease without local or systemic progression exists in subjects with the II-genotype significantly longer than in subjects with the DD genotype (p=0.01). With the presence of an II-genotype, there was also a tendency towards a thinner intima-media thickness. We found significant correlations between intima-media thickness and age (p<0.0001), fasting serum insulin (p=0.001), and lipoprotein (a) (p=0.008). CONCLUSIONS: In the present study involving patients with stage II peripheral arterial occlusive disease, ACE gene polymorphism could not be identified as a determining marker for the development of intima-media thickening in the common carotid artery. However, it can be assumed that there is a reduced risk for the systemic progression of atherosclerosis in patients with the II genotype.

[Ultrasound image of the hypothenar hammer syndrome]. / Das sonographische Bild des Hypothenar-Hammer-Syndroms.

UNLABELLED: A traumatic lesion of the ulnar artery (Hypothenar Hammer Syndrome, HHS) is a very rare cause of acral ischemia of the upper extremity. AIM: Evaluation of the efficacy of ultrasound techniques in the diagnosis of the HSS. METHOD: Based on the knowledge of the patient's history and clinical examination we investigated forearm, hand and digital arteries by continuous wave Doppler. By means of colour-coded duplex sonography (CCDS) we demonstrated the course of the radial and ulnar arteries to the palmar arch. For comparison we used the results of preintervention angiography. RESULTS: The diameter of the distal ulnary artery measured in healthy women was 1.8 +/- 0.32 and in men 2.2 +/- 0.46 mm. Among 268 patients with ischemia of the hands we diagnosed HHS in four cases. We identified an aneurysm of the ulnary artery in one case and a thrombotic occlusion in three cases. The thrombotic occlusion of the ulnar artery led to a dilatation of the vascular lumen. The occlusion length could be determined. Vessels diameter and echogenecity gave information about the age of the thrombosis. CONCLUSION: The continuous wave Doppler is a major diagnostic contribution because of its ability to register hemodynamic changes. Additionally, CCDS with its combination of sonomorphology and hemodynamics enables a distinction between HHS and other causes of digital ischemia. The CCDS more precisely refines the indications for preinterventional angiography in acute ischemia syndromes of the hand.

Angiotensin-converting enzyme gene insertion/deletion polymorphism and peripheral arterial occlusive disease.

BACKGROUND: The deletion polymorphism of the ACE gene is linked to a high risk of cardiovascular disease due to the permanent activation of the local and systemic renin-angiotensin systems (RAS). The aim of this prospective study was 1. to compare the ACE insertion/deletion polymorphism in individuals with a healthy vasculature with that of patients suffering from peripheral arterial occlusive disease (PAOD), and 2. to determine whether associations existed between specific clinical parameters and the ACE genotype which the PAOD patients expressed. PATIENTS AND METHODS: Determinations of ACE I/D gene polymorphism were made using a polymerase chain reaction (PCR) technique on 98 patients with clinical stage II PAOD according to Fontaine and 240 healthy individuals who served as controls. All patients and controls came from central Germany. Clinical variables which included duration of clinical symptoms, a familial history of the disease, arteriosclerosis score (ASF, providing an estimate of the extent of atheromatosis at femoral artery bifurcation) and plasma ACE activity were correlated with the genotypes taking the cardiovascular disease risk factors which were present into consideration. RESULTS: Differences in ACE genotypes between patients with PAOD (D/I: 0.57/0.43) and control group individuals (D/I: 0.59/0.41) were not observed. In comparison with the II genotype, the DD genotype was associated with a shorter duration of disease (p = 0.01), a positive family medical history (p = 0.022) and a higher plasma ACE activity (p = 0.026). The ASF did not correlate with the ACE I/D gene polymorphism. CONCLUSION: Evidence that the deletion allele is linked to the manifestation of PAOD could not be found in the patients studied. One can assume, however, that the deletion allele has a progression promoting effect on the disease.

[Quantitative sonography of peripheral arteriovenous malformations]. / Quantitative Sonographie peripherer arteriovenöser Malformationen.

UNLABELLED: Congenital vascular malformations occur in 1.5% of the general population. Depending on their localization and morphology, with dysfunction of local and central hemodynamics as well as tissue metabolism, congenital peripheral arteriovenous malformations (AVM) are of particular importance within the larger, heterogeneous group of diseases which comprise vascular malformations. AIM: The aim of this study was to evaluate our ability to quantity peripheral congenital AVM using sonographic, functional-hemodynamic, and morphological parameters. METHOD: Apart from obtaining a medical history and applying clinical and venous occlusion plethysmographic diagnostics, sonographic examinations of peripheral arteries and veins using cw-Doppler sonography and color-coded duplex sonography were performed on 8 patients with peripheral congenital AVM. For comparative purposes, the results of pre-intervention angiography examinations were also considered. RESULTS: For a sonographic quantification of AVM at the time of diagnosis, during assessments of diseases progress, and postinterventionally, both the resistance index of Pourcelot and measurement of the vascular blood flow velocities appeared to be particularly appropriate as functional-hemodynamic parameters. The sonomorphological parameters reflect the individual vascular pathology, which is determined by hemodynamic changes. CONCLUSION: Functional-hemodynamic and sonomorphologic parameters allow a quantification of AVM. With knowledge of the clinical picture acquired at the time, they provide the basis for deciding upon a more extensive pre-interventional invasive radiological diagnosis.

[Ultrasound-controlled cutting biopsy for collecting histologic specimens]. / Ultraschallgezielte Schneidbiopsie zur Gewinnung von histologisch auswertbarem Material.

The fine-needle puncture under ultrasound guidance has the disadvantage that the material obtained can only be evaluated by cytology. The cutting biopsy cannula represents a compromise between the fine and the Menghini needle. In this way, small tissue cylinders can be attained. The aim of the present study was to investigate to what extent the sampled specimen could be assessed by cytology or histology. Fine-needle puncture resulted in 22 (69%) out of 32 cases in material suitable for cytology. Cutting biopsy led in 34 out of 36 cases (94%) to specimen valid for histology. Thus, cutting biopsy clearly extends our diagnostic tools. It is not yet clear at present whether procedures with a higher risk - such as the Menghini puncture - can be in part replaced by alternative ones.

[Pedicled fibroma of the extrahepatic bile ducts]. / Gestieltes Fibrom der extrahepatischen Gallenwege.

It is reported on the very rare occurrence of a benign tumor in common hepatic bile duct of a 33-year-old woman, associated with obstructive jaundice. Clinical diagnosis and treatment are described, histological typing like fibroblastic tumor with neurogenic parts are discussed and a short review of the literature is given.