[Repeated local thrombolysis in a patient with axillary and subclavian vein injury and thrombosis]. / Opakovaná lokální trombolýza u poranení a trombózy axilární a podklíckové zíly.

Deep vein thrombosis (DVT) is a disorder with blood clot (thrombus) formation in deep veins. DVT of upper extremities (UE) is rare but serious, bearing in mind its possible complications, disease. UE DVT treatment involves subcutaneous injections of low molecular weight heparins and subsequent switch to oral anticoagulation or thrombolysis; thrombolysis by intravenous administration of a thrombolytic agent is used only if indicated (subclavian vein thrombosis). A case of a professional sportswoman is presented, who was treated for venous thrombosis of subclavian and axillary veins using local thrombolysis. Thrombosis emerged suddenly after a basketball match, during which oedema of the right arm occurred subsequent to the patient being hit with the ball to the armpit area. Venipuncture as well as all catheter repositionings were performed under the duplex ultrasound (DUS) surveillance. Proximal brachial vein was punctured and four French catheters were used to enter subclavian vein. For thrombolysis, 0.2-0.6 mg/hour alteplase (rt-PA) was used. Injury to axillary vein tunica intima was evident the following day after the subclavian and axillary thrombosis was dissolved completely, and thrombosis in the same area recurred immediately after stopping the thrombolytic infusion. Therefore, administration of a thrombolytic agent into the same area was re-introduced and acetylsalicylic acid was added to the medication. This combined therapy resulted in recanalization of the arm as well as the axillary and subclavian areas. Thrombolysis was stopped on the 3rd day of treatment. The method can be used to manage deep vein thromboses of the upper arms even without X-ray control. Local thrombolysis of deep vein thrombosis with ultrasound surveillance is, in indicated patients, a safe method even if a vein injury occurs.

Pedal bypass grafting on arteriographically invisible foot arteries detected by duplex ultrasound for limb salvage.

AIM: In this study the long-term outcomes in patients undergoing pedal bypass grafting were evaluated and the risk of graft occlusion was related to whether, preoperatively, the pedal arteries were visualized by angiography or not and were only detected by duplex ultrasonography. METHODS: In 2000-2005, 81 pedal bypass grafts were performed in patients with chronic critical lower-limb ischemia, of which 54 (66.7%) had diabetes. Tissue loss (SVS/ISCVS-category 5) was recorded in 68 (84%) limbs and rest pain (SVS/ISCVS-category 4) in 13 (16%) limbs. In 24 limbs (29.6%) bypass grafts were implanted on the pedal arteries that had not been visualized by preoperative angiography, but had been detected only by duplex ultrasound. RESULTS: During the follow-up (median, 17 months; range, 3-69 months), 18 grafts (22.2%) failed. Seven limbs had to be treated by early thrombectomy, which resulted in long-term graft patency and limb salvage. The early postoperative mortality rate was 2.5%. Cumulative primary and secondary graft patency rates, and limb-salvage rates were 70.2%, 80.2% and 82.4%, respectively. No significant difference in graft occlusion was found between the patients with visible and those with not visible pedal arteries on preoperative arteriograms (Fisher's exact test). CONCLUSIONS: Duplex ultrasonography is a reliable modality for detection of target pedal arteries not visualized by preoperative arteriography and it helps reduce the number of patients with non-operable arterial occlusion disease by about 25%.

[Monitoring functional disorders of microcirculation using laser doppler flowmetry in patients with chronic venous insufficiency class 2 according to CEAP classification before and after varicose veins surgery]. / Sledování funkcních poruch mikrocirkulace laser dopplerem u pacientu s chronickou zilní nedostatecností trídy 2 dle CEAP klasifikace pred a po operaci varixu.

INTRODUCTION: Laser Doppler flowmetry is a sensitive modern method for evaluating the function of small veins which allows for the detection and assessment of early pathological changes in microcirculation. The method uses a low power laser beam which is emitted into the tissue where it is reflected and further recollected and analysed. The objective of the study was to compare laser Doppler flowmetry parameters for patients with chronic venous insufficiency (class 2 according to CEAP, primary varices) prior to and 1 month after surgery of varicose veins. METHODOLOGY AND PATIENT SAMPLE: The examination was performed by a Periflux laser Doppler apparatus made by Perimed. Blood flow was examined on the dorsal side of foot fingers. A total of 42 patients were examined prior to and one month following the varicose veins surgery, of whom 28 women and 14 men. The mean age of the patient sample was 49 years. A 45 minute pre-op and post-op recording of the limb was made for each patient. The protocol consisted of a 10 minute recording in rest, followed by a 4 minute ischemisation of the limb with the use of a blood pressure measuring cuff, subsequent release of the cuff, a 15 minute recording of the reperfusion and a test of vasodilatation using nitrate, and a 10 minute recording following vasodilatation. Evaluation was performed for a 4 minute period at the end of the initial rest period, for reperfusion after the release of the cuff and for the interim period of rest immediately preceding the application of nitrate, and finally for a 5 minute period after nitrate application. Statistical evaluation was performed for data acquired during the movement of blood elements and data acquired in the frequency analysis of the movement of the blood vessel wall. 3 variables were chosen for the statistical evaluation of the blood cell movement data: "the area under the curve", "the mean value of the deviation" and "the percentage change" in the different phases of the measurement, i.e. as compared with the rest recording: comparing the ischemisation and the rest recordings, comparing the vasodilatation and the rest recordings, and comparing the restitution and the rest recordings. The above variables were not assessed as absolute numbers but as the difference of values before and after the surgery. The above differences were tested in the Wilcoxon test. The intensity of blood vessel movements in the frequency range from 0.008 to 0.200 Hz and 0.210-0.420 Hz was evaluated in frequency analyses. RESULTS: Significant differences in peripheral microcirculation in lower limbs were found in the evaluation of data acquired during the movement of the different blood elements before and after varicose vein surgery (p = NS). On the contrary, evaluation of frequency analysis for both the operated and non-operated limb shows a decrease in spontaneous arterial reactivity after varicose vein surgery. This decrease is statistically significant in the frequency range from 0.102 to 0.228 on operated limbs after the removal of a varix in a T1 test (i. e. after reperfusion) as compared with the values before the surgery (p < 0.05). CONCLUSION: Varicose vein surgery results in the reduction of spontaneous vasomotion in the periphery of the operated limb.

[Assessment of changes in peripheral microcirculation in type I diabetics with laser doppler flowmetry]. / Zmeny periferní mikrocirkulace u diabetiku 1. typu sledované laser dopplerem.

GOAL: To make out a methodology and assessment of peripheral microcirculation with laser Doppler flowmetry (LDF) in patients with type I diabetes mellitus and to compare their results to findings in healthy control people using frequency analyses. METHODOLOGY: A group of 32 patients suffering from type I diabetes on an average for 14 years (group A) has been examined. The patients suffered from a basic angiology disorder in arteries of lower extremities. Peripheral circulation in lower extremities has been examined via laser Doppler flowmetry. The same tests have been done in a group of 40 healthy people (group B). RESULTS: Basic evaluation revealed no statistical differences between groups A and B at rest (TO). Significant differences showed up during vasodilation test (T2). Intensity of perfusion in group A was 37 +/- 23 arbitrary perfusion units (PU) compared to 81 +/- 43 PU in group B (p < 0.001). During perfusion following ischemisation (T1) levels of blood circulation in groups A and B were 71 +/- 39 PU compared to 121 +/- 89 PU (p < 0.018). During frequency analyses the intensity of slow vasomotion (SV) in group A was already generally lower at rest (TO) 0.46 +/- 0.42 PU compared to 1.12 +/- 0.62 PU (p < 0.011) in group B. During the reperfusion phase following ischemisation (T1) intensity of SV was 1.8 +/- 0.78 PU compared to 2.82 +/- 1.58 (p < 0.17). Following vasodilation test (T2) perfusion was 0.79 +/- 0.65 PU compared to 1.86 +/- 1.31 (p < 0.009). In areas of fast vasomotion (FV; frequency 0.210 - 0.420 Hz) there were significant differences between group A and B at rest (TO) and during vasodilation test (T2). At rest 0.08 +/- 0.02 PU compared to 0.19 +/- 0.05 PU (p < 0.006). During vasodilation test 0.14 +/- 0.03 PU compared to 0.28 +/- 0.11 PU (p < 0.004). CONCLUSION: This study presents an original examination protocol and findings. Significant differences were identified in peripheral circulation of patients suffering from solely type I diabetes mellitus and control people. So called spontaneous venous reactivity (vasomotion) was in type I diabetics significantly lower already at rest and especially in reaction to vasodilation stimulus. The differences can't be still clearly explained but there is a suspicion they are a result of an impaired endotelial and autonomous function in type I diabetes mellitus. The method of frequency analyses of LDF records enables to give precision to peripheral blood circulation evaluation. It could be used to detect early changes in blood circulation as early as at rest.

[Diabetic peripheral arterial disease]. / Diabetické periferní tepenné postizení.

Macrovascular impairment of peripheral arteries in diabetes mellitus corresponds with such an impairment in atherosclerosis. Furthermore, peripheral angiopathy, microangiopathy, and polyneuropathy resulting from microangiopathy develop in diabetes. Impairment of microcirculation worsens peripheral blood flow. Infection and insufficient trophism worsen state. A wide range of factors participate in development of vascular disease in diabetes with adverse influence both on veins and reactions coming under rheology, haemocoagulation, and immune reactions. In type II diabetes an average interval of arterial impairment is 9-10 years, in type I diabetes approximately 17-22 years. A relative risk of non-traumatic amputation of a lower limb in diabetics is several times higher than in non-diabetics. A prevention of lower limbs impairment in diabetics is the most efficient method of reducing risk of amputation. An intervention therapy, endovascular intervention or angiosurgery are indicated in patients with clinical problems. A state of distal bed is an important factor for success of interventions. As a pivotal drug treatment in intervention and traditional methods is considered an effective antiaggregation treatment. A diabetic peripheral arterial disease is a complex disease requiring a wide view and considering various and changing pathophysiological mechanisms.

[Lipids and atherosclerosis of the peripheral vessels]. / Lipidy a ateroskleróza periferních cév.

The authors present a review of information on the incidence éf obliterations of peripheral vessels, incl. their own experience, with a group of diabetic patients. Attention is paid to the pathophysiology of affections of peripheral vessels. In the final part data on the relationship of lipids or their fractions and the development of obliteration of peripheral vessels are presented.