Fatal basilar artery occlusion under dabigatran occurring 13 days after femoral embolectomy.

A male with atrial fibrillation for 30 years underwent embolectomy in his right leg at age 78 years. Postoperatively, he received enoxaparin 60 mg/twice a day (bid), and on day 5, phenprocoumon was started. The patient's son, a general practitioner, changed phenprocoumon to dabigatran 110 mg/bid on day 8. Pain in his left calf induced readmission after 5 days. International normalized ratio was 2.5 and D-dimer was 20 µg/mL. Dabigatran was stopped and dalteparin 5000 International Units/bid and 40 µg alprostadil infusions were started. After 8 hours, he became comatose due to basilar artery occlusion and eventually died. This tragic case raises the issue of postoperative use of dabigatran, a recently introduced thrombin inhibitor.

Austrian Joint ÖGGH-ÖGIR-ÖGHO-ASSO position statement on the use of transarterial chemoembolization (TACE) in hepatocellular carcinoma.

Transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC) is one of the most frequently applied standard treatments for this disease. The role for TACE is fairly well defined within the most widely used treatment algorithm for HCC, die Barcelona Clinic Liver Cancer (BCLC) staging system and treatment algorithm. But no general treatment algorithm will go into the technical details of any procedure and several patients will not fit ideally into the patient groups predefined in BCLC or any other treatment algorithm. Furthermore, indications and contraindications sometimes are viewed differently by the various medical specialties involved in taking care of such patients. We present here the joint expert position statement of the Austrian Societies of Gastroenterology and Hepatology (ÖGGH), Interventional Radiology (ÖGIR), Hematology and Oncology (ÖGHO), and Surgical Oncology (ASSO) on the technical aspects, indications, and contraindication for the use of TACE in the management of HCC.

Quality of life in patients with idiopathic subclavian vein thrombosis.

INTRODUCTION: Idiopathic subclavian vein thrombosis (SVT) is a rare disease but these otherwise healthy patients often suffer from prolonged clinical manifestations. The aim of this retrospective study was to assess the range and severity of thrombosis-related disability of the upper extremity in patients after an episode of documented idiopathic SVT in the long-term follow-up. MATERIALS AND METHODS: The quality of life (QoL) of 37 patients with documented idiopathic SVT was assessed by two standardized questionnaires (DASH and SF 36). The DASH and SF-36 questionnaire each use a 100 point scale. 0 stands for uncompromised functioning, 100 for maximum limitation in the DASH, while in the SF-36 0 marks the lowest rating of QoL and 100 indicates the best imaginable quality of life. RESULTS: Mean follow-up time was 120+/-80.1 months (range: 14 to 286 months). The mean DASH score was 10.7+/-12 and the mean scores for the SF-36 dimensions Physical Component Summary (PCS) and Mental Component System (MCS) were 52+/-9.3 and 46.3+/-9.5, respectively. CONCLUSIONS: Patients suffering from idiopathic SVT report good overall QoL judged by the mean DASH and satisfactory QoL by the SF-36 score in the long-term follow-up. These patients deal well with their physical limitations.

Multidetector CTA in the quantification of internal carotid artery stenosis: value of different reformation techniques and axial source images compared with selective carotid arteriography.

PURPOSE: To evaluate the role of 4 different reformation techniques and axial images from multidetector computed tomographic angiography (MDCTA) versus selective carotid arteriography (SCA) in patients with internal carotid artery (ICA) stenosis. METHODS: Imaging studies from 50 patients (43 men; mean age 70.3+/-8.0 years, range 51-85) with known cerebrovascular disease who underwent MDCTA and SCA in a single university hospital were retrospectively analyzed. Axial images, multiplanar reformation (MPR), curved planar reformation (CPR), volume rendering threshold (VRT), and virtual angioscopy (VA) images were reviewed by 2 independent observers who were blinded to the results of SCA, which served as the gold standard. The degree of stenosis was categorized as 0%-49%, 50%-69%, or 70%-99%; a stenosis >70% was considered as hemodynamically significant. RESULTS: Thirty-four hemodynamically significant stenoses were identified on SCA. The agreement with SCA images was good for both observers using axial CT images (kappa = 0.89 for observer 1 and 0.88 for observer 2); corresponding results for MPR and CPR were kappa = 0.91 and 0.92 for observer 1 and 0.88 and 0.91 for observer 2, respectively. VRT (kappa = 0.72 for observer 1 and 0.66 for observer 2) and VA (kappa = 0.74 for observer 1 and 0.70 for observer 2) showed a slightly inferior correlation with SCA images. Sensitivities for reformations and axial CT images were 100% each; corresponding specificities ranged from 85% to 95%. CONCLUSION: Axial images as well as all 4 reformation techniques agreed well with SCA in the grading of ICA stenosis.

Increasing carotid plaque echolucency is predictive of cardiovascular events in high-risk patients.

PURPOSE: Carotid plaque echolucency seen at ultrasonography (US) is a potential indicator of plaque instability and may help identify patients at risk for major adverse cardiovascular events (MACEs). The authors performed this study to determine whether decreasing gray-scale median (GSM) levels at repeat carotid US examinations are associated with future MACEs. MATERIALS AND METHODS: The study was approved by the institutional ethics committee and all patients provided informed consent. The authors prospectively studied 574 patients with carotid plaques of at least 30% from a group of 1268 consecutive patients who were initially asymptomatic with respect to carotid disease. GSM levels were determined with carotid US at baseline and after a median of 7.5 months (range, 6-9 months), and the mean change of the GSM was calculated. Patients were then followed up clinically for a median of 3.2 years for the occurrence of composite MACE. RESULTS: During the initial period, the median change in carotid GSM was 2.9 (interquartile range [IQR], -6.9 to 11.0). Of 574 study participants, 230 (40%) showed a reduction of GSM levels and 344 (60%) showed an increase. MACEs were observed in 177 (31%) of the 574 patients. Adjusted hazard ratios for the lowest quartile (GSM change less than -6.9), the second quartile (GSM change between -6.9 and 2.9), and the third quartile (GSM change between 3.0 and 11.0) were 1.71 (95% confidence interval [CI]: 1.09, 2.66), 1.36 (95% CI: 0.86, 2.16), and 1.22 (95% CI: 0.77, 1.95), respectively, compared with the highest quartile (GSM change greater than 11.0) (P = .018). CONCLUSION: Increasing echolucency of carotid artery plaques within a 6- to 9-month interval is predictive of midterm clinical adverse events of atherosclerosis.

Assessment of intima-media thickness of carotid arteries: evaluation of an automated computer software.

INTRODUCTION: The aim of this study was to evaluate the feasibility and accuracy of commercially available software directly implemented on the ultrasound scanner for automated measurement of the intima-media thickness (IMT) of the common carotid artery on source images. MATERIALS AND METHODS: Measurements were performed on a GE Vivid 3 ultrasound scanner. First, inter- and intraobserver correlations were assessed for the automated and the manual measurements. Second, the correlation between automated and manual measurements was assessed in 199 asymptomatic patients with a mean age of 30 years (range 20-41 years). RESULTS: The measurement was feasible in all patients and a standard configuration with optimum quality was determined. The inter- and intraobserver correlations obtained using the automated software were excellent and slightly inferior to the manual measurements. The correlation of the automated and manual measurements was significant (r = 0.86; P < 0.01) and the mean difference between both measurements was low (0.023 +/- 0.034 mm). CONCLUSIONS: The software allowed an efficient and quick measurement by providing at the same time comparable results to the manual measurement and a better inter- and intraobserver variability.

CTA quantification of internal carotid artery stenosis: application of luminal area vs. luminal diameter measurements and assessment of inter-observer variability.

BACKGROUND AND PURPOSE: In contrast to digital subtraction angiography (DSAdia), computed tomography angiography (CTA) provides exact delineation of the perfused lumen in the axial plane, thus allowing luminal (CTAdia) as well as cross-sectional area (CTAarea) internal carotid artery stenosis (ICAS) assessment. The purposes of the present study were to correlate CTAdia and CTAarea with DSAdia and to assess the inter-observer variabilities of both CTA techniques. METHODS: In a retrospective analysis, CTA images were reviewed by two observers and ICAS was assessed according to North American Symptomatic Carotid Endarterectomy Trial applying CTAdia and CTAarea. DSAdia was assessed by a third observer. RESULTS: Based on 54 consecutive patients (40 males [74.1%] and 14 females [25.9%]; median age 73.3 years), ICAS percentages of CTAdia and CTAarea revealed significant correlations with DSAdia (r= 0.79-0.87, all P<.001) with median differences in the range of +8% to -6%. Inter-observer agreement was moderate for CTAdia (kappa= 0.60) and excellent for CTAarea (kappa= 0.86). Sensitivity of CTAarea for the detection of ICAS >70% was 100% for both observers, corresponding results for CTAdia were 97.1% and 71.4%, respectively, using DSAdia as the gold standard. CONCLUSION: CTAarea assessment of ICAS correlates well with the results of DSAdia and provides an excellent sensitivity for the detection of ICAS >70% with superior inter-observer agreement compared to CTAdia.

Skin tissue cholesterol is not related to vascular occlusive disease.

The objective of the present study was to evaluate the role of skin tissue cholesterol (SkinTc) in predicting the presence of atherosclerosis. SkinTc concentrations were determined in 318 consecutive patients by using the non-invasive PREVU POC Skin Sterol Test. Additionally, a complete lipid status and cardiovascular risk profile according to the PROCAM and Framingham scores as well as an evaluation by carotid duplex sonography and ankle-brachial blood pressure index testing was obtained from all patients. SkinTc concentrations did not differ significantly among patients suffering from cerebrovascular disease (CVD) and peripheral arterial disease (PAD) compared to the corresponding control groups and among patients with a calculated cardiovascular risk > 10% in 10 years compared to patients with a risk < 10% (all p > 0.05). Additionally, SkinTc concentrations were not significantly higher in the 245 patients with at least one documented atherosclerotic disease compared with the remaining 73 patients without evidence of atherosclerosis. In conclusion, SkinTc concentrations determined by the PREVU POC Skin SterolTest are not related to the presence of CVD and PAD or to an elevated cardiovascular risk, indicating that this parameter cannot be used as a reliable indicator of atherosclerosis.

CTA in the detection and quantification of vertebral artery pathologies: a correlation with color Doppler sonography.

INTRODUCTION: We evaluated the feasibility of multidetector CT angiography (MDCTA) in the examination of vertebral artery (VA) pathologies and correlated the results with those of color Doppler sonography (CDS). METHODS: In this retrospective cohort analysis, we identified 65 patients with suspected cerebrovascular disease, who underwent MDCTA and CDS of the supraaortic vessels within a maximum period of 1 month. We evaluated the feasibility and image quality of MDCTA in this indication, compared the value of reformatted images and axial source images in the grading of stenoses and correlated these results with those of CDS. RESULTS: The image quality of the MDCTA examination was classified as good in 64 patients (98.5%) and as moderate in 1 patient (1.5%). Axial source images and reformatted images agreed perfectly in terms of stenosis detection and grading as well as the detection of hypoplastic VAs (kappa = 1). The correlation between MDCTA and CDS was moderate (kappa = 0.56) in terms of stenosis detection and quantification and poor (kappa = 0.35) in terms of detection of hypoplasia of the VA. CONCLUSION: MDCTA is a feasible method for the evaluation of VA pathologies providing a good image quality. Image reformatting does not add any diagnostic value to the interpretation of axial source images. The correlation between MDCTA and CDS is only moderate, reflecting the clinically important limitations of CDS in this indication.

The cardiovascular risk marker asymmetrical dimethylarginine is not affected by venous thromboembolism.

Asymmetrical dimethylarginine (ADMA) is an endogenous inhibitor of endothelial nitric oxide synthase, causes vasoconstriction, impairs cardiac function, and may predict cardiovascular risk. The prognostic value of plasma ADMA concentrations in acute vascular situations may be confounded by concomitant factors such as clot formation. In an effort to address the effect of hemostatic system activation, the authors have measured plasma concentrations of ADMA, its stereoisomer symmetrical dimethylarginine (SDMA), and L-arginine in 74 patients with suspected deep vein thrombosis (DVT). DVT was confirmed by sonography or venography in 39 subjects. There was no difference of L-arginine, ADMA, or SDMA (all P > 0.05) between subjects with or without DVT. ADMA correlated with SDMA, L-arginine, and plasma creatinine (all P < 0.05) but not with age, body mass index, D-dimer, thrombus extension, or history of symptoms. Venous thrombembolism does not influence circulating ADMA concentrations. The lack of association between ADMA and DVT argues against a contribution of endogenous NO synthase inhibition in hemostatic systemic activation.

Plaque echolucency is not associated with the risk of stroke in carotid stenting.

BACKGROUND AND PURPOSE: Plaque characteristics are suggested to play a potentially important role as risk factors for poor outcome after carotid artery stenting (CAS). We therefore correlated objectively and subjectively determined carotid plaque morphology with neurological complications after CAS. METHODS: We enrolled 698 consecutive patients undergoing elective CAS from a prospective single-center registry database and classified the preinterventional plaque status according to gray-scale median levels and the standardized Beletsky and Gray-Weale plaque scores. Patients were followed for 30-day neurological complications. RESULTS: Neurological complications including transient ischemic attack, minor and major stroke occurred in 5.9% (41/698) of the patients. Median gray-scale median, Beletsky and Gray-Weale scores were 45 (interquartile range [IQR] 25 to 70), 3.0 (IQR 2.0 to 3.0) and 2.0 (IQR 2.0 to 3.0), respectively. None of the scores was significantly associated with adverse outcome adjusting for traditional risk factors, medication, preinterventional symptoms, degree of stenosis, contralateral occlusion and use of cerebral protection, neither with respect to all neurological complications nor with respect to stroke and death (all P>0.05). CONCLUSIONS: Plaque echolucency measured by objective and subjective grading did not identify patients with an increased risk of peri-interventional neurological events. Evaluation of plaque echolucency therefore cannot be recommended for risk stratification in CAS patients.

Endovascular repair of inflammatory aortic aneurysms: long-term results.

OBJECTIVE: Our objective was to report the long-term follow-up results of endovascular aneurysm repair of inflammatory aortic aneurysms. CONCLUSION: Endovascular aneurysm repair of inflammatory aortic aneurysms excludes the aneurysm and seems to reduce the size of the aneurysmal sac and the extent of periaortic fibrosis with acceptable periinterventional and long-term morbidity.

Treatment of gastro-jejunal leakage and fistulization after gastric bypass with coated self-expanding stents.

Leakage and fistulization of the gastro-jejunostomy have been the major drawback of Roux-en-Y gastric bypass (RYGBP) surgery. Most authors agree that operative treatment is the mainstay of therapy in patients with signs of sepsis. However, intestinal contents causing localized infection may impede healing of sutured leaks in some patients, and fistulas develop. Because the anastomosis cannot be disconnected or exteriorized for anatomical reasons, other forms of treatment have to be applied. The following case-reports describe a technique with implantation of coated self-expanding stents. Leakage of the gastro-jejunostomy occurred in one patient 3 days after RYGBP and resulted in formation of a fistula. A fistula developed in a second patient 63 days after RYGBP. Coated self-extending stents were implanted endoscopically in both patients on postoperative days 19 and 67. Enteral nutrition could be started 6 days later. Stents were removed 2 months after implantation without problems. Weight loss and quality of life 7 and 21 months after stent removal have been excellent in both patients. Implantation of coated self-expanding stents was an effective and minimally invasive option for gastro-jejunal anastomotic fistulas after RYGBP where surgical repair was not possible. In these cases, application of stents allows septic source control without any other intervention.

Endovascular therapy of inflammatory aortic aneurysms: a meta-analysis.

PURPOSE: To report a meta-analysis of results from endovascular aneurysm repair (EVAR) of inflammatory aortic aneurysms (IAA). METHODS: A comprehensive literature review was performed to identify all studies reporting the results of EVAR in patients with IAA. To be included in the analysis, an article had to provide a minimum follow-up of 6 months, information about primary technical success, details of immediate and long-term complications, and evaluation of at least one of the basic outcome criteria: changes in aneurysm sac diameter, periaortic fibrosis (PAF), and/ or renal impairment. All studies were reviewed by 2 independent observers for the inclusion criteria. Data were retrieved on the technical and clinical success, outcome criteria, mortality in follow-up, and reinterventions from 14 articles selected from among 701 initially identified. RESULTS: The 14 articles encompassed 46 patients (45 men [97.8%]; mean age 65 years, range 59-75) with a mean follow-up of 18 months after endovascular repair of IAAs located in the abdominal aorta. The primary technical success rate was 95.6% (44/46) and the 30-day clinical success rate was 93.4% (43/46). The median aneurysm sac diameter regression was 11 mm. Of 43 patients with PAF prior to the intervention, 22 (51.2%) patients showed complete regression, 18 (41.8%) remained unchanged, and 3 (7.0%) showed progression after EVAR. Renal impairment disappeared in 11 (45.8%) of 24 patients. Reinterventions were reported in 8 patients. The procedure-related and follow-up mortality rates were 0% and 13.0%, respectively. CONCLUSIONS: EVAR of IAA is feasible, excludes the aneurysm effectively, and reduces PAF and renal impairment in most patients with very low periprocedural and midterm mortality and an acceptable reintervention rate.

Multidetector CT angiography with perfusion analysis in the surveillance of renal artery stents.

PURPOSE: To evaluate 4 perfusion parameters obtained by multidetector computed tomographic angiography (CTA) in the follow-up of patients after renal artery stenting. METHODS: Thirty-three consecutive patients (20 women; mean age 64.3+/-10.7 years) with renal artery stents were included in this prospective pilot trial. CTA was performed in 21 patients on a 4-row scanner and in 12 patients on a 16-row scanner. Volume maximum intensity projections and curved planar reconstructions were used for morphological analysis. The initial contrast test bolus was used for perfusion imaging by placing 2 additional regions of interest in the cortex of each kidney. The maximum relative attenuation values (Hounsfield units [HU max]), the time-to-peak values, an attenuation ratio, and a time-to-peak ratio for each side were calculated. RESULTS: Over a mean follow-up of 3.4+/-1.7 years, restenosis was detected in 4 (12.1%) of the 33 stents; in all 66 main renal arteries, 5 (7.5%) significant flow obstructions were detected. Interobserver agreement for all morphological parameters was excellent (kappa>0.8). Mean relative HU max for the cortical region of stented arteries was 63.7+/-29.7 (mean HU ratio 0.37+/-0.12); the mean TTP max was 32.9+/-7.4 seconds (mean ratio 0.76+/-0.10). None of the perfusion parameters differed significantly between patients with and without significant flow obstructions (p>0.05). CONCLUSIONS: Despite the excellent morphological information provided by multidetector CTA in the follow-up of renal stents, this modality does not provide hemodynamic information. Unfortunately, none of the evaluated perfusion parameters added any useful information in the follow-up after renal artery stenting.

The role of soluble cell adhesion molecules in patients with suspected deep vein thrombosis.

Activation of the endothelium, platelets and leukocytes has been shown to play an important role in the aetiology of deep venous thrombosis (DVT) in in-vitro experiments, resulting in the release of soluble cell adhesion molecules (sCAMs). We therefore assessed the value of soluble intracellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), soluble E-selectin and soluble P-selectin for the diagnostic process in 69 consecutive patients with suspected DVT. Final diagnosis was based on the results of Duplex sonography or ascending venography. Thirty-seven patients (53.6%) finally suffered from DVT. Mean levels of sVCAM-1 were 589 +/- 530 ng/ml for controls and 587 +/- 328 ng/ml for patients. Corresponding levels concerning sICAM-1 were 316 +/- 161 and 342 +/- 186 ng/ml, those concerning soluble E-selectin were 54 +/- 38 and 42 +/- 18 ng/ml, and those concerning soluble P-selectin were 94 +/- 37 and 99 +/- 36 ng/ml (all P > 0.05). There was no significant correlation of the thrombus extension (all P > 0.05) or the duration of symptoms with sCAMs (all P > 0.05). In conclusion, we detected no significant differences concerning the concentration of four major sCAMs between patients with DVT and controls, so their assessment does not add any useful information for the diagnostic process of DVT.

Three-dimensional color Doppler sonography in carotid artery stenosis.

BACKGROUND AND PURPOSE: Color Doppler sonography (CDS) suffers from such disadvantages as high interobserver variability and problems with data presentation and storage. We therefore performed a prospective trial to assess the role of three-dimensional CDS (3D-CDS) in the evaluation of internal carotid artery stenosis (ICAS). METHODS: We included 32 consecutive patients with sonographically verified ICAS (30-99%) and 16 asymptomatic volunteers. All underwent CDS and 3D-CDS, and 23 patients also underwent intraarterial angiography. The sensitivity, specificity, positive predictive value, and negative predictive value for the detection of high-grade ICAS were analyzed by three blinded readers, who also graded the percentage of ICAS. RESULTS: CDS revealed 14 patients with mild to moderate ICAS and 18 patients with high-grade ICAS. Mean sensitivity of 3D-CDS was 81.5%, mean specificity was 98.9%, mean positive predictive value was 97.9%, and mean negative predictive value was 89.9%. 3D-CDS correlated significantly with CDS (mean r=0.85; P<.001) and angiography (mean r=0.57; P=.01). CONCLUSION: 3D-CDS findings correlate with those obtained by CDS and angiography; 3D-CDS also offers excellent interobserver correlation, positive predictive value, and specificity, approaching 100% for the detection of high-grade ICAS.

The effect of low-dose simvastatin in children with familial hypercholesterolaemia: a 1-year observation.

UNLABELLED: Familial hypercholesterolaemia (FH) is a severe disorder of lipid metabolism associated with an enhanced risk to develop cardiovascular disease later in life, with atherosclerotic lesions beginning already in childhood. These are facts which make an early diagnosis and therapy necessary to prevent or delay such complications. The aim of this study was to investigate the efficacy and safety of low-dose simvastatin, a potent HMG-CoA reductase inhibitor, in children and adolescents with FH. Therefore, 20 children and adolescents (12 females, 8 males) aged between 10 and 17 years with FH were recruited for this 1-year simvastatin study. According to baseline levels of low density lipoprotein (LDL)-C, girls and boys were divided into two groups, one group (with LDL-C <220 mg/dl) starting with a simvastatin dosage of 5 mg/day, the other (with LDL-C >220 mg/dl) 10 mg/day with the possibility to increase dosages up to a daily maximum of 20 mg, if not reaching LDL-C concentrations of <170 mg/dl within the first period. Every 4-8 weeks, weight, height, lipids, Lp(a) and routine safety parameters of all participants were determined by a paediatrician, documenting exactly all side-effects. The percentage decrease was 25% for LDL-C in the 5 mg simvastatin period (19% for total cholesterol (tChol)), 30% for LDL-C in the 10 mg period (26% for tChol) and 36% decrease for LDL-C in the 20 mg period (29% for tChol). The changes for high density lipoprotein (HDL)-C were -5.9% (5 mg), +2.9% (10 mg) and -10.9% (20 mg) the percentage decrease in triglycerides was 12.6% (5 mg), 14.3% (10 mg) and 21% (20 mg). The side-effects of simvastatin were of no clinical relevance and all disappeared after a couple of days. CONCLUSION: our results showed that simvastatin seems to be an effective and safe medical therapy even in children and adolescents with familial hypercholesterolaemia.