Stenting of common iliac vein obstructions combined with regional thrombolysis and thrombectomy in acute deep vein thrombosis.

OBJECTIVES: To evaluate the efficacy of stent placement after infrainguinal loco-regional thrombolysis and iliac thrombectomy (surgical TT) of acute deep vein thrombosis (DVT) in patients with May-Thurner-Syndrome. MATERIAL AND METHODS: We retrospectively analysed a group of 11 patients (9 women) (mean age 34 years, range 16-64 years) with surgical TT and additional intra-operative stenting due to compression of the common iliac vein. Patients underwent venography to demonstrate outflow patency after surgical TT, and to identify any obstruction at the level of the left-sided common iliac vein ("Beckenvenen-Sporn"). Obstruction at the level of arterial crossing was treated using Wallstents placed via an introducer sheath from the inguinal access site. Stents were fully deployed using balloons adjusted to the size of vein. Patients were treated with oral anticoagulants for 6 months, and followed using duplex ultrasonography. RESULTS: Technical success defined as complete vein patency and normal valve function was documented in all 11 patients. One patient needed early stent extension due to residual stenosis. At 6 months follow-up one patient (9%) had an asymptomatic occlusion of the stented common iliac vein. In all 11/11 (100%) patients the femoral segment was found to be patent, and in 1/11 (9%) there was mild reflux with few clinical symptoms of post-thrombotic syndrome. The calculated cumulative primary patency rate for venous iliac stents was 82%, and assisted patency rate was 91%, which remained unchanged over a mean follow-up of 22 months. CONCLUSION: Combining surgical TT and stenting of common iliac vein obstructions in DVT is safe, effective, and results in a acceptable venous patency.

Lymphatic clearance of the human skin in patients with acute deep vein thrombosis using a novel fluorescent technique.

The purpose of this study was to investigate lymphatic clearance of the human skin in patients with acute deep thrombosis of the femoral vein. In 13 patients with deep vein thrombosis and no other cause for swelling of the limbs, lymphatic clearance of the skin at the foot was measured. Ten microliters of fluorescein isothiocyanatedextran 150,000 were injected intradermally and the fluorescent light intensity of the deposit measured 10 min and 24 hours after injection by window densitometry. In addition, intralymphatic pressure was measured by the servo-nulling system. The results were compared with a sex- and age-matched control group. Fluorescent light intensity decreased by 23.8 +/- 12.3 arbitrary units or by a factor of 1.8 +/- 0.5 in patients with DVT after 24 hours, which was significantly less than in healthy controls (33.7 +/- 8.9 arbitrary units or by factor 5.0 +/- 4.1, p < 0.013). Intralymphatic pressure was not different between the two groups. These results indicate that lymphatic clearance is significantly reduced in the acute phase of deep venous thrombosis.

Acroparesthesia and acral arterial occlusions as first manifestations of essential thrombocythemia.

Thrombocytosis is either caused by a reactive process (secondary thrombocytosis) or by a clonal bone marrow disorder The latter category includes essential thrombocythemia with bleedings and thrombotic complications as major causes of illness and death in this patients. We describe a 43-year-old man with a 6 months history of acroparesthesia in his toes. Half a year after onset of these symptoms, he noticed a bluish discoloration of digit V of his left foot. On first presentation physical examination revealed a bluish discoloration of all toes and a cold and blue digit V of the left foot. Peripheral pulses were all palpable, normal ankle systolic pressure measurements and normal pulse volume recordings except for digit V of the left foot were found. Laboratory tests revealed thrombocytosis of 800000/microliter. On treatment with acetylsalicylacid, prostanoids intravenously and low molecular weight heparin, the patient became asymptomatic and pulse volume recording of digit V was normalized. After exclusion of cardial or vascular sources of embolism by utrasonography bone marrow aspirate and biopsy supported the diagnosis of essential thrombocythemia.

Haemodynamic effect of intermittent pneumatic compression of the leg after infrainguinal arterial bypass grafting.

BACKGROUND: Intermittent pneumatic compression (IPC) may increase blood flow through infrainguinal arterial grafts, and has potential clinical application as blood flow velocity attenuation often precedes graft failure. The present study examined the immediate effects of IPC applied to the foot (IPC(foot)), the calf (IPC(calf)) and to both simultaneously (IPC(foot+calf)) on the haemodynamics of infrainguinal bypass grafts. METHODS: Eighteen femoropopliteal and 18 femorodistal autologous vein grafts were studied; all had a resting ankle : brachial pressure index of 0.9 or more. Clinical examination, graft surveillance and measurement of graft haemodynamics were conducted at rest and within 5 s of IPC in each mode using duplex imaging. Outcome measures included peak systolic (PSV), mean (MV) and end diastolic (EDV) velocities, pulsatility index (PI) and volume flow in the graft. RESULTS: All IPC modes significantly enhanced MV, PSV, EDV and volume flow in both graft types; IPC(foot+calf) was the most effective. IPC(foot+calf) enhanced median volume flow, MV and PSV in femoropopliteal grafts by 182, 236 and 49 per cent, respectively, and attenuated PI by 61 per cent. Enhancement in femorodistal grafts was 273, 179 and 53 per cent respectively, and PI attenuation was 63 per cent. CONCLUSION: IPC was effective in improving infrainguinal graft flow velocity, probably by reducing peripheral resistance. IPC has the potential to reduce the risk of bypass graft thrombosis.

Measurement of the lymphatic clearance of the human skin using a fluorescent tracer.

The lymphatic clearance of the human skin at the instep of the foot was measured in 20 healthy volunteers (mean age +/- SD 33.8 +/- 10.5 years). Ten microliters of fluorescein isothiocyanate-dextran 150,000 were injected intradermally and the fluorescent light intensity of the deposit was measured 10 min and 24 h after injection by window densitometry. Fluorescent light intensity decreased by 31.2 +/- 13.5 arbitrary units (p < 0.0001) or by a factor of 4.1 +/- 3.9. Reproducibility was tested 2-6 weeks later in 7 subjects and an intraclass reliability of 0.76 was found. These are the first measurements of the lymphatic clearance of the human skin using a fluorescent tracer. The method is easier and safer than the isotope clearance technique and small areas of the human skin can be investigated. The data found form a basis with which to compare measurements made in patients with different forms of edema.

Effects of intermittent pneumatic compression of the calf and thigh on arterial calf inflow: a study of normals, claudicants, and grafted arteriopaths.

BACKGROUND: Recent data indicate that intermittent pneumatic compression (IPC) of the foot may offer benefits in patients with intermittent claudication exceeding those of standard medications approved by the Food and Drug Administration. IPC of the foot (IPC(foot)) and calf (IPC(calf)) increases flow velocity in infrainguinal arterial bypass grafts and thus may prevent arterial thrombosis. Our aim was to evaluate the acute effects of IPC of the thigh (IPC(thigh)), IPC(calf), and IPC of the thigh and calf (IPC(calf + thigh)) in healthy controls, claudicants, and arteriopaths who have undergone infrainguinal bypass grafting for critical or subcritical limb ischemia. METHODS: Sixteen limbs of normals (group A), 17 limbs of claudicants (group B), and 16 limbs of arteriopaths (group C) who had undergone infrainguinal autologous revascularization were studied. Blood flow was measured in the limbs of normals and claudicants in the popliteal artery and in the grafts of revascularized limbs by using duplex ultrasonography. Mean velocity (mV), peak systolic velocity, end diastolic velocity (EDV), pulsatility index (PI), and volume flow (Q) were measured in the sitting position at rest and within 10 seconds from the delivery of IPC(thigh), IPC(calf), and IPC(calf + thigh), IPC was delivered at maximum inflation and deflation pressures of 120 mm Hg and 0 mm Hg, respectively; inflation and deflation times of 4 and 16 seconds, respectively; and a proximal inflate delay of 1 second (calf compression preceding that of thigh). RESULTS: In all 3 groups with all IPC modes, the Q, mV, and EDV increased while PI decreased (P <.05). IPC(thigh) was less effective than IPC(calf), but still increased Q (by 114%, 57%, and 59.8% in groups A, B, and C, respectively) and EDV, while decreasing PI in all 3 groups (P <.05). IPC(calf + thigh) was the most efficient mode, generating an increase in the median Q of 424% in controls, 229% in claudicants, and 317% in grafted arteriopaths. The addition of IPC(thigh) to IPC(calf) increased the mV and Q in group A (P < or = .044); the mV, Q, and EDV in group B (P < or = .03), and mV and PI by 24% and -27% in group C, respectively. CONCLUSIONS: IPC applied to the thigh, either alone or in combination with IPC(calf), generates native arterial and infrainguinal autologous graft flow enhancement. The paucity of conservative methods available for lower limb blood flow augmentation may allow IPC of the lower limb to emerge as a reliable, noninvasive therapeutic option, ameliorating claudication and assisting infrainguinal bypass graft flow. IPC(thigh) adds to the armamentarium of currently known IPC options (foot or calf) promoting its applicability and efficacy.

Lymphoedema, lymphatic microangiopathy and increased lymphatic and interstitial pressure in a patient with Parkinson's disease.

New microvascular findings in a woman with Parkinson's disease and lower leg oedema are presented. Microlymphography showed enhanced filling of the microlymphatic network with the fluorescent contrast medium comparable to the findings in lymphoedema. The microlymphatic and interstitial pressures of the skin were increased (27 mm Hg and 16 mm Hg respectively). The increased interstitial and microlymphatic pressures are the result of insufficient venous and lymphatic drainage due to impairment of calf muscle function during walking in Parkinson's disease. Manual lymph drainage and compression therapy, in combination with improvement of calf muscle function, resulted in regression of the oedema.

Extracellular magnesium depletion in pediatric patients with insulin-dependent diabetes mellitus.

It is unclear whether insulin-dependent diabetes mellitus is a state of magnesium depletion. This is a relevant question, since magnesium deficiency has been implicated in the pathogenesis of diseases that develop to an increased extent into diabetes mellitus. Total plasma magnesium was not statistically different in 76 pediatric patients with insulin-dependent diabetes mellitus (0.77 [0.73-0.81] mmol/l; median and interquartile range), 59 healthy adults (0.80 [0.77-0.83] mmol/l) and 19 healthy children (0.80 [0.78-0.83] mmol/l). In contrast, plasma ionized magnesium, the most interesting form with respect to physiological and biological properties, was significantly lower in diabetic patients (0.50 [0.48-0.53] mmol/l) when compared with healthy adults (0.53 [0.50-0.56] mmol/l; p < 0.01) and healthy children (0.54 [0.51-0.56] mmol/l; p < 0.02). Our report confirms recent findings of reduced circulating ionized magnesium but normal circulating total magnesium in adults with non-insulin-dependent diabetes mellitus.