Association between pre-PTCA blood haemoglobin concentration and the risk of symptomatic restenosis after successful PTCA of primary coronary stenoses.

BACKGROUND: Thrombus formation at the dilation site has been suggested to initiate the restenosis process after percutaneous transluminal coronary angioplasty (PTCA). High haemoglobin concentrations may predispose to thrombus formation by increasing blood viscosity, slowing coronary blood flow and increasing thrombocyte adhesion. METHODS: Pre-PTCA blood haemoglobin concentrations (Hb) in 44 patients with symptomatic restenosis > or = 50% of the vessel diameter (Group A) were compared with Hb in the remaining 215 patients in a consecutive study population (Group B). RESULTS: Median Hb (range) was 149 (119-164) g/l in Group A and 142 (117-164) g/l in Group B, P = 0.004. Odds ratio (95% CI) for symptomatic restenosis was 3.22 (1.62-6.42) when Hb was dichotomised according to the median in the entire material. Hb, but not sex was a significant risk factor in multivariate analysis. CONCLUSION: Hb is a hitherto not recognized factor associated with the risk of symptomatic restenosis after PTCA and may be a link coupling male sex with increased risk of restenosis.

Transient release of lipid peroxidation products as a non-invasive marker of successful reperfusion after thrombolysis for myocardial infarction.

OBJECTIVES: To evaluate an increase in plasma concentration of thiobarbituric acid reactive substances as a non-invasive biochemical test of reperfusion after thrombolysis and to investigate the relation between the inflammatory response after acute myocardial infarction and the production of the substances. METHODS: Venous samples were taken from 19 patients receiving thrombolysis for acute myocardial infarction before the start of therapy and every hour afterwards up to 5 hours and then at 24 and 48 hours and the concentration of thiobarbituric acid reactive substances measured. These substances are markers of lipid peroxidation induced by free oxygen radicals. Early reperfusion was judged by regression of ST elevation and late coronary artery patency from the results of coronary angiography 24-72 hours after thrombolysis. RESULTS: The concentration of thiobarbituric acid reactive substances increased in only 6 out of 14 patients with signs of early reperfusion. In patients with late coronary artery patency the corresponding number was 6 out of 15. However, a significant increase in the concentration of thiobarbituric acid reactive substances was found for the whole group 24 and 48 hours after treatment. The change in concentration in serum correlated significantly with that of C reactive protein--an acute phase reactant (r = 0.62, P < 0.01)--but not to the serum activities of markers of infarct size such as creatine kinase B and lactate dehydrogenase. CONCLUSIONS: The fluorimetric assay used in this study to measure the concentration of thiobarbituric acid reactive substances seems to be an insensitive method of detecting reperfusion after thrombolysis for myocardial infarction. The increase in concentrations found 24 and 48 hours after treatment correlated with C reactive protein concentrations but not with those of markers of infarct size.

To what extent does peripheral vascular disease and hypertension predict renal artery stenosis?

The incidence of renal artery stenosis (RAS) was prospectively evaluated by aortofemoral angiography in 100 patients with peripheral vascular disease (PVD) to find whether RAS was a more common finding in hypertensive than in normotensive patients. For a possible association with RAS, risk factors, clinical and angiographical variables were evaluated. Nephrotoxicity of the contrast medium Iohexol was elucidated. A follow-up of six month was performed in patients with severe stenosis or total occlusion of the renal arteries. Of the 49 patients with a renal artery lesion 26.5% were normotensive and 73.5% hypertensive. Hypertension was significantly correlated to RAS. Reconstructive vascular procedures were during the follow-up performed in 47.3% of the patients with severe RAS or occluded renal arteries, two patients underwent a renal artery revascularization, none of them got a postoperative blood pressure decrease. Hypertension in patients with peripheral vascular disease is predictive for renal artery stenosis and a possible renovascular hypertension should be evaluated. Surgery for renal artery stenosis in peripheral vascular diseased patients should, however, probably be performed firstly to reduce the risk for occlusion. The effect on the blood pressure can not be predicted without a more careful analysis that the blood pressure is renin-dependent. Iohexol showed low nephrotoxicity, also in patients with renal artery disease.

Renal artery stenosis in patients with peripheral vascular disease and its correlation to hypertension. A retrospective study.

To estimate the frequency of renal artery stenosis, and to detect the correlation between renal artery stenosis and hypertension, 450 consecutive patients with peripheral vascular disease (PVD) were selected. All subjects had undergone aorto-femoral conventional angiography. For a possible association with renal artery stenosis, risk factors, clinical and angiographical variables were evaluated e.g.: age, sex, diabetes mellitus, smoking habits, use of antihypertensive drugs, serum creatinine, serum cholesterol, ECG pathology, side of the renal artery lesion, bilateral stenoses, post-stenotic dilatation, number of renal arteries, aortic atherosclerosis, size of the kidneys and angiography induced renal dysfunction. Renal artery stenosis (RAS) was found in 49.1%, 117 patients had a moderate and 104 had a severe stenosis. Of the 221 patients with a renal artery lesion, 44 were normotensive, 177 hypertensive. Hypertension was significantly correlated to RAS. An association was also found for age over 70 years, smoking and pathologic ECG. It is concluded that renal artery stenosis is very common in a population with peripheral vascular disease, and the results achieved from this study makes it worthwhile to identify possible functional markers in a prospective study.

Surgical treatment versus thrombolysis in acute arterial occlusion: a randomised controlled study.

Thrombolytic treatment has been tried in various forms for acute limb ischaemia with varying degrees of success but is also often accompanied by bleeding problems. The present investigation compares the effect of surgical thrombectomy (TE) and thrombolysis (TL) using recombinant tissue plasminogen activator (rt-PA). Twenty patients with a need for intervention owing to ischaemia lasting more than 24 h but less than 14 days were included. Patients randomised to TE were operated under epidural anaesthesia and patients in the TL group received 30 mg rt-PA during a 3 h period through a catheter placed into the thrombus and advanced as lysis was achieved. Thrombectomy resulted in an immediate restitution of blood flow in six out of nine cases, in three cases a bypass procedure was performed, and one of these failed with a resultant amputation. Thrombolysis gave a good primary result in six cases which lasted in four of them. Three had a subsequent percutaneous transluminal angioplasty. Partial lysis was seen in two cases and a further two failed. Five went to surgery with three bypass and two fogarty procedures being necessary. There was no hospital mortality and there were no bleeding complications due to the rt-PA treatment in this series. In 19 out of 20 patients the circulation was re-established. Appropriate handling of acute ischaemic conditions implies the use of both thrombolysis and appropriate surgical procedures, including distal bypass grafts.

Patency after iliac and femoro-popliteal angioplasty. Difference between angiographic and clinical results.

Twenty-five patients with clinical relapse after previous successful angioplasty of iliac or femoro-popliteal arteries were evaluated with repeat angiography. The angiographic patency was 80% despite the clinical symptoms. The discrepancy between the angiographic appearance and the clinical findings was explained by the progress of the general arteriosclerotic vascular disease. Such progression is more important regarding late prognosis than the result of the angioplasty per se.

Peritoneal ovarian metastases simulating liver parenchymal metastases.

Ovarian carcinoma frequently metastasizes to the peritoneum, both locally in the pelvis and elsewhere. Computed tomography (CT) has a limited ability to identify peritoneal implants with a diameter of 2 cm or less. Three cases of subphrenic, diaphragmatic peritoneal implants, preoperatively at CT thought to represent liver parenchymal metastases, are presented. The difficulty in the differentiation of diaphragmatic peritoneal implants from metastases to the capsule and parenchyma of the liver is discussed. To achieve a radical liver resection in patients with ovarian carcinoma, metastatic peritoneal implants must be excluded during operation.

Effect of chemotherapy and radiotherapy on squamous cell carcinoma of the esophagus. A preoperative radiologic evaluation.

In a series of 82 patients with epidermoid carcinoma of the esophagus, 68 were available for review of barium examinations and 44 for review of CT examinations showing the effect of preoperative treatment. After 3 courses of chemotherapy--Cisplatinum and 5-fluorouracil, and 24 Gy of presurgical irradiation--over a total of 10.5 weeks, the patients were ready for surgery. The results of the presurgical radiographic examinations were compared with the findings of histopathologic studies after surgery. Where both the CT and the barium examination showed a complete response, none of the patients had remaining macroscopic cancer. When healing with stenosis was included, CT and barium studies in combination were necessary to exclude a residual macroscopic tumor. Therefore, a combination of barium esophagography and CT is recommended to estimate the preoperative effect of treatment.

Visceral ischemia following aortic surgery.

Intestinal ischemia after aortic surgery is a rare (1-5%) complication, often with a fatal outcome (greater than 50%). During the period 1974-1987, 554 abdominal aortic operations were performed in our department. 17 patients (3%) were reoperated due to bowel ischemia, ten of these patients died. 12 patients were operated on due to aortic aneurysm (9 emergency operations) and 5 due to occlusive disease. A retrospective analysis of the files of the 17 patients was performed to try to identify the risk patient. Preoperative investigations demonstrated that the inferior mesenteric artery (IMA) was patent in 3 patients and occluded in 5 patients. As to the other 9 patients no information could be found (all with aneurysm). After the primary operation, 11 patients had persistent circulation via at least one of the hypogastric arteries and none of them had persistent circulation via the IMA. 11 patients had bloody diarrhea before reoperation and in 6 patients peritonitis was observed. Rectoscopy was performed in 8 patients and in 7 there was indication of ischemia. The most common finding among the laboratory tests was a rise in the creatinine level which was observed in 10 patients. Other laboratory tests such as blood gases, leucocytes, thrombocytes or temperature were of little predictive value per se. Patients operated on due to ruptured aortic aneurysm are risk patients. No other predictive symptom or sign was found to preoperatively identify the patient at risk for intestinal ischemia. An intraoperative method for evaluating the intestinal blood flow would be of great value when considering selective intestinal vascular reconstruction.

CT demonstration of fistulae in patients with gynecologic neoplasms.

Ten women treated for gynecologic neoplasms (8 cervical carcinomas, one vaginal and one endometrial carcinoma) were found at computed tomography (CT) to have a fistula although only 5 patients had symptoms that could be related to a fistula. Five women had vesico-vaginal fistulae, 2 recto-vaginal, 2 entero-cervical and one a vulvo-pubical fistula. We regard CT as the radiologic method of choice in diagnosing gynecologic fistulae.

Increased rate of left predominance associated with adult valvular aortic stenosis.

The anatomy of the coronary arteries was outlined angiographically in 2,190 adult patients in order to determine the proportion of left predominance. Of 253 patients with valvular aortic stenosis 14.3 per cent were found to have left predominance, while the frequency of left predominance in the rest of the patients (1937) was 8.5 per cent. Furthermore, this rate increases with the severity (gradient greater than 50 mmHg) of the aortic stenosis in the absence of aortic valve incompetence. These findings support the current concept of a relationship between adult aortic stenosis and congenital valvular malformation.

The influence of a heart level pillow on the result of blood pressure measurement.

Measurement of blood pressure is subject to two sources of variation: biological variation between and within individuals and measurement variation introduced by the observers. Concerning the latter variation it is important to take into consideration arm position in relation to heart level. To improve the standardisation of arm position in relation to the heart level in the supine position, a special pillow--the heart level pillow--was developed. The distances between the examination couch, the centre of the right cardiac atrium, and the sternum were measured by computerised tomography. The upper arm diameter was determined with vernier callipers. These values were then used to design and manufacture a heart level pillow. Blood pressures were then measured on 78 adult patients both with and without the pillow. When blood pressure was measured with the arm at heart level diastolic blood pressure was on average 5.5 mmHg lower compared with measurements performed without the pillow. Therefore, we conclude that a heart level pillow may reduce one common and important error in the indirect measurement of blood pressure.

Staging in local endometrial carcinoma. Assessment of magnetic resonance and ultrasound examinations.

Possible deep (more than an inner third of the uterine wall) myometrial invasion and cervical extension of endometrial carcinoma were evaluated prospectively using magnetic resonance (MR) and transabdominal real-time sonography (US) in 20 and 10 patients, respectively. The data obtained from these examinations were compared with hysterosalpingography (HSG) and clinical modalities including hysteroscopy, sounding and histopathologic findings after surgery. The concordance of outlining cervical extension was between MR and hysteroscopy 85 per cent, and between US and hysteroscopy 50 per cent. Deep myometrial tumor invasion was suggested in 4/10 patients by US and in 6/20 by MR, and was confirmed in all but one in each group at histologic examination of the resected uterus. There were no false negative US or MR examinations. Transabdominal US did not prove accurate in defining local endometrial carcinoma (distinguishing between stages I and II), but it may be used as an additional tool in revealing myometrial invasion. MR, however, seems to refine the delineation of uterine tumor growth.

Spontaneous resolution of a descending aortic dissection. Report of a case.

The natural history of an aortic dissection is either endothelialization of the false lumen forming a so-called double-barrelled aorta, or thrombosis of the sack leading to fibrosis and scarring. Complete healing of an aortic dissection is extremely rare, and has to our knowledge only been reported once in vivo. Here we report a second case of spontaneous resolution of an aortic dissection, disclosed by contrast medium enhanced computed tomography.

Computed tomography of malignant ovarian disease.

One hundred and five patients with proven malignant ovarian disease were examined with one or more abdomino-pelvic CT scans in order to evaluate clinically suspected recurrence, complete clinical remission, or the effect of therapy. The findings obtained at CT were compared with follow-up examinations including surgery in 85 patients within 3 months. CT was accurate in the evaluation of therapeutic response, but if negative not reliable enough to replace a laparotomy of patients with possible recurrence or in clinical remission.

Computed tomography of the thymus gland in myasthenia gravis.

Sixteen consecutive patients with myasthenia gravis were examined by computed tomography (CT) before thymectomy. Surgical and histologic findings were compared with those obtained at CT. The results, like those of most other recent studies, indicate that CT is a reliable method for identifying thymoma. In all three patients with thymoma, and in five out of eight patients with hyperplasia, the lesion was observed at CT, giving an overall accuracy of 80 per cent. Although thymic hyperplasia is a basically histologic diagnosis an enlarged gland may give a correct diagnosis of this abnormality.