bluuebunny/crossref_metadata_2025 huggingface dataset:
Zum Rezidivrisiko nach venöser Thromboembolie
Authors: Kyrle  , Eichinger
Published: January 2006

Venous thromboembolism (VTE) is a chronic rather than acute disease. After withdrawal of secondary thromboprophylaxis, many patients will experience a subsequent episode of thrombosis. Of these patients, approximately 5% will die from pulmonary embolism. The risk of recurrent VTE depends on the number of risk factors and their severity. High-risk patients, i.e. those with a natural coagulation inhibitor deficiency, recurrent thrombosis, active cancer, the lupus anticoagulant or compound clotting defects most probably benefit from indefinite oral anticoagulation. In these patients the risk of bleeding due to anticoagulant treatment seems to be outweighed by the risk of VTE. Patients with hyperhomocysteinemia or high factor (F) VIII plasma levels are also at an increased risk of recurrence. The optimal duration of secondary thromboprophylaxis in these patients is currently under investigation. Patients with the heterozygous F V Leiden mutation or the G20210A mutation in the F II gene do not require extended anticoagulation since their risk of recurrence is similar as in patients without the aforementioned mutations. Patients with VTE secondary to surgery or trauma have a relatively low risk of recurrence. In these patients short-term secondary thromboprophylaxis (6 to 12 weeks) is justified whereas patients with a first episode of spontaneous VTE should be treated with oral anticoagulants for a longer period of time (3 to 6 months).
Evaluation von Messmethoden zur Erfassung der Durchblutung bei chronischer kritischer Extremitätenischämie
Authors: Zwicky  , Mahler  , Baumgartner
Published: January 2006

Background: Evaluation of macro- and microcirculatory tests to confirm diagnosis, and recognize perfusion changes in chronic critical limb ischemia (CLI). Patients and methods: Forty-two consecutive patients with CLI examined at the University Hospital Bern, with 21 included in this prospective follow-up analysis. Patients underwent serial clinical examinations, and assessment of the macro- (ankle arterial pressure [AP], great toe pressure [TP], oscillography) and microcirculation (transcutaneous partial oxygen pressure [tcPO2] recumbent, sitting, O2-inhalation; capillary microscopy) at baseline, 6 weeks after revascularization (group 1; [n = 11]), or after 10 weeks in patients unsuitable for revascularization (group 2; [n = 10]). Clinical improvement was considered to indicate increased perfusion. Results: Eleven patients with revascularization (11/11), and 2 without revascularization (2/10) showed clinical improvement. AP measurements were not reliable or feasible in 9 (43%), TP in 4 patients (19%), respectively. All measurable pressures were in accordance to clinical course. Oszillography gave a moderate perception of perfusion changes. Baseline tcPO2 levels were critical (< 30 mmHg) in all 21 patients, whereas follow-up gave poor correlation with the clinical course. Reliability to detect perfusion changes increased by adding provocation manoeuvers in patients with clinical improvement (39% [5/13] recumbent, 77% [10/13] sitting, 85% [11/13] O2-inhalation). Capillary microscopy revealed a relevant pathology at the forefoot level in all patients with feasible examinations (18/21), and significant improvements according to the clinical course in 92% of patients (12/13). Conclusions: TP measurements represented most reliable test to confirm diagnosis and disclose improved perfusion in CLI. TcPO2 measurements in recumbent position gave unreliable results, improved by provocation manoeuvers. Capillary microscopy was reliable, but time consuming and limited by anatomical restrictions.
Prädilektion des Malleolus medialis beim mit hämolytischer Anämie assoziierten Ulcus cruris
Authors: Sawhney  , Weedon  , Gillette  , Solomon  , Braverman
Published: January 2006

Backround: Ischemic ulcers are usually found above the lateral, and venous stasis ulcers at the medial malleoli. Leg ulcers occur in at least 25% of sickle cell disease (SSD) patients in clinic populations, usually in the malleolar region. The function of the large leg veins in most SSD patients is unimpaired. Patients and methods: We determined leg ulcer location in 41 sickle cell anemia (SS), and 4 sickle-b0 thalassemic patients with longstanding chronic and/or recurrent leg ulceration, and reviewed published reports of leg ulcers in hereditary spherocytosis and thalassemias. Results: Of the 57 legs of the 45 SSD patients with only 1 ulcer, 42 (74%) were medial and 15 lateral. The difference was significant (p < 0.001). Of patients with only a single ulcer, 22 were medial and 4 lateral. Of 15 reported patients with leg ulcers related to spherocytosis or thalassemia, 20/24 (83%) ulcers were medial. Conclusions: The medial malleoli are the most common site of leg ulceration in SSD and in other chronic hemolytic anemias. This suggests that stasis may play a role in the leg ulceration associated with chronic hemolytic anemia.
Nicht invasive Tests zur Risikostratifizierung bei großen gefäßchirurgischen Eingriffen
Authors: Mondillo  , Ballo  , Agricola  , Guerrini  , Barbati  , Ammaturo  , Bertelli  , Neri  , Sassi
Published: January 2006

Background: The predictive values of noninvasive tests versus perioperative cardiac events in patients undergoing major vascular surgery has not been definitively established. Patients and methods: According to clinical markers and left ventricular function at rest, 188 patients were assigned to the following groups: 40 low, 115 moderate and 33 high risk. They were then randomly submitted to dipyridamole (n = 64), dobutamine (n = 63) stress echocardiography and dipyridamole perfusion scintigraphy (n = 61). Results: No events were observed in low-risk patients, whereas 12 (10.4%) and 8 (24%) events in moderate- and high-risk categories occurred, respectively. Only the high-risk category, as a predictive variable, was significantly related to the onset of cardiac complications (p < 0.05). A positive dipyridamole/dobutamine stress test was related to cardiac events, but multivariate analysis showed that only severity and extent of ischemia were the best predictors of events (p < 0.01 for dipyridamole and p < 0.005 for dobutamine). The presence of reversible, but not fixed, perfusion defects at scintigraphy was significantly related to perioperative events; at multivariate analysis, only > 3 reversible perfusion defects represented a strong predictor of events (p < 0.05). Conclusions: Among subjects undergoing major vascular surgery, severity and extent of ischemia during dipyridamole/dobutamine stress echocardiography and presence of > 3 reversible perfusion defects are strong predictors of cardiac events, particularly in moderate-risk category of patients.
Prostanoide in der Behandlung der Claudicatio intermittens – eine Metaanalyse
Authors: Reiter  , Bucek  , Stümpflen  , Dirisamer  , Minar
Published: January 2006

Background: Numerous studies have established the efficacy of prostanoids in PAD stages III and IV, but the role of prostanoids as an alternative or additive treatment in patients suffering from PAD II is less clear. To resolve this uncertainty we performed a meta-analysis of all randomised controlled studies analysing effects of prostanoids in patients suffering from intermittent claudication. Methods: 96 studies have been screened by computerised searches of MEDLINE and EMBASE. Relevant studies were pooled in Cochrane’s Review-manager 4.1. Results: 19 studies were included for further analysis. Five studies could not be pooled for analysing walking distances, because standard deviations were not stated. Eight studies compared effects of any prostanoid iv vs. placebo. In total 557 patients (281/276) were included for analysis of painfree – walking distance (PFWD) and 519 patients (262/257) for analysis of maximum walking distance (MWD). Prostanoids compared to placebo significantly improved mean PFWD by 28% (7%–49%, P = 0,008) and mean MWD by 30% (11%–50%, P = 0,002). At least one adverse reaction was reported from 39,6% of the patients treated with prostacyclin and its analogues and from 13,7% of the patients treated with prostaglandin E1. Conclusion: Patients suffering from intermittent claudication benefit from administration of prostaglandin E1 by a significant improvement of their walking capacity.
The role of perforating vein dissection in the treatment of venous ulceration – myth and evidence
Authors: Klein-Weigel  , Biedermann  , Fraedrich
Published: January 2006

Das Ulcus cruris venosum stellt die schwerste Form der chronischen venösen Insuffizienz (CVI) dar. Nach duplexsonographischen Untersuchungen überwiegen in diesem Stadium Insuffizienzen des epifaszialen Venensystems, kombinierte oberflächliche und tiefe Insuffizienzen sind jedoch häufig. Zwar korreliert die Anzahl insuffizienter Perforansvenen mit dem Schweregrad der CVI, alleinige Perforans-Insuffizienzen sind bei venösen Ulzera aber sehr selten. Da zudem nur ein kleiner Teil der insuffizienten Perforantes größere Refluxvolumina aufweisen, sind Zweifel an einer ursächlichen Beziehung zwischen Perforans-Insuffizienz und Ulkusentstehung begründet. Phlebodynamometrischen Studien zufolge steigt das Risiko für die Entwicklung eines venösen Ulkus mit der Schwere der hämodynamischen Dekompensation. Eine dauerhafte Ulkusheilung ist nur bei einer Normalisierung der ambulatorischen venösen Hypertonie zu erwarten. Bei Insuffizienz des oberflächlichen Venensystems und begleitender Perforans-Insuffizienz genügt hierzu ausschliesslich die Ausschaltung der epifaszialen Refluxkomponente. Die Funktion der Perforantes erholt sich danach konsekutiv. Im Gegensatz hierzu persistiert die venöse Hypertonie nach Sanierung der epifaszialen Insuffizienzen auch nach zusätzlicher Ausschaltung insuffizienter Perforantes, wenn eine irreversible Schädigung des tiefen Venensystems vorliegt. Die Resultate dieser pathophysiologischen Untersuchungen spiegeln sich exakt in den Ergebnissen chirurgischer Therapiestudien wider, die dargelegt werden. Bei kritischer Sichtung dieser Literatur bleibt der Stellenwert der endoskopischen subfaszialen Perforans-Dissektion (ESPD) im Behandlungskonzept des venösen Ulkus weiterhin unklar. Zukünftige Studien können die potentielle Wertigkeit der Perforans-Dissektion nur dann definitiv beurteilen, wenn auf eine gleichzeitige Saphena-Ausschaltung verzichtet wird. Therapiestudien zum Stellenwert der ESPD sollten darüber hinaus stärker als bisher das behandelte Patientengut unter Verwendung der CEAP-Einteilung und der Hach’schen Klassifikation pathophysiologisch charakterisieren und technische Unterschiede sowie die Radikalität des Eingriffes berücksichtigen.
getABI: Deutsche epidemiologische Studie zum Knöchel Arm Index bei älteren Patienten in hausärztlicher Betreuung
Authors: Diehm Curt
Published: January 2006

Background: Peripheral arterial occlusive disease (PAD) is a common, but widely underestimated disease associated with a high morbidity and mortality risk. PAD can be regarded as an indicator for a generalized atherothrombosis. In view of the scarcity of appropriate representative data from Germany, we set up a large-scale epidemiological prospective observational study. Patients and methods: The primary objectives of the study comprise the estimation of the actual prevalence of PAD in unselected elderly patients, the determination of the risk factor profile of these patients, the incidence of the disease, as well as the relative risk of death due to any cause or cardiovascular, cerebrovascular or vascular events, respectively, of PAD patients compared to those without PAD, in representative primary health care settings. In addition, awareness of the problem of the disease PAD and its implications on the part of the treating physicians is determined by a Physician Awareness Questionnaire. Results: After having been trained by 34 centers of excellence (angiologists), 344 general practitioners have recruited 6880 patients aged 65 years or older and will follow them up over 3 years. Key examinations include bilateral Doppler sonographic measurements and determination of the ankle brachial index (ABI) under standardized conditions during rest and exercise, laboratory evaluations at baseline including homocysteine, physical examinations, and the WHO Rose questionnaire. The study is purely observational and no interventions are planned or stipulated. Conclusions: The getABI cohort is an important contribution to the widely neglected research area in general practice in Germany. Data from research in general practice represent the foundation for medical decision making in the sense of evidence based medicine.
Thrombophlebitis assoziiert mit Injektionsanästhetika: Einfluss der Armposition
Authors: Pingsmann  , Kröger  , Patsalis  , Voges  , Drebes
Published: January 2006

Background: Thrombophlebitis (TP) is a frequent complication of the intravenous application of injection anaesthetics. We investigated the influence of different arm positions on the incidence of such a complication in patients undergoing shoulder arthroscopy. Patients and methods: This prospective, randomised study was done in 86 consecutive major shoulder arthroscopies. In order to evaluate the influence of different arm positions, the arm not operated on was positioned either cranial (n = 31) or caudal (n = 55) to the level of the right atrium. The number of TP in the 5 days following the arthroscopy was detected clinically and proven by ultrasound studies. Results: 8 TP occurred in the group of patients with caudal arm positioning and none in the other group. Statistically, the incidence of TP was not associated with the weight or the height of the patients nor with the duration of the anaesthesia or the doses of anaesthetics used in each patient (p < 0.05). Conclusion: An elevated position of the arm used for anaesthesia during shoulder arthroscopy is suggested in order to prevent TP.
Prädiktoren der Mortalität bei rupturierten Aortenaneurysma
Authors: Gutiérrez-Morlote  , Llorca  , Ibáñez de Elejalde  , Lobato  , San José
Published: January 2006

Background: A study was designed to determine significant variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm. Patients and methods: Data of 106 unselected consecutive patients with ruptured abdominal aortic aneurysm undergoing operation between 1989 and 1998 were identified from a prospective hospital-based registry. A total of 32 variables were analyzed including demographic characteristics, vascular risk factors, coexisting conditions, preoperative findings, intraoperative variables, and postoperative complications. Preoperative and intraoperative variables related to vital status (alive, death) in the univariate analysis were subjected to stepwise linear regression analysis to determine whether a combination of variables would predict death. Of 99 evaluable patients, 48 died (mortality rate 48.5%). Results: At univariate analysis, age, serum creatinine, hemoglobin, electrocardiographic ischemia, loss of consciousness on admission, preoperative shock, supra-renal rupture, and transfusion requirements were significantly associated with 30-day operative mortality. Postoperative complications except sepsis, mesenteric ischemia, and neurologic events were significantly associated with mortality. Electrocardiographic ischemia, shock, and supra-renal rupture appeared to be independent predictors of mortality in the multivariate analysis. The cumulative effect of 0, 1, and => 2 risk factors on mortality was 29%, 39%, and 90%, respectively. Conclusions: Electrocardiographic ischemia, preoperative shock, and supra-renal rupture were predictors of death in patients with ruptured abdominal aortic aneurysm.
Aneurysms in the history of medicine
Authors: Bollinger  , Rüttimann
Published: January 2006

Die Geschichte des sackförmigen oder fusiformen Aneurysmas reicht in die Zeit der alten Ägypter, Byzantiner und Griechen zurück. Vesal 1557 und Harvey 1628 führten den Begriff in die moderne Medizin ein, indem sie bei je einem Patienten einen pulsierenden Tumor intra vitam feststellten und post mortem verifizierten. Weitere Eckpfeiler bildeten die Monographien von Lancisi und Scarpa im 18. bzw. beginnenden 19. Jahrhundert. Die erste wirksame Therapie bestand in der Kompression des Aneurysmasacks von außen, die zweite in der Arterienligatur, der John Hunter 1785 zum Durchbruch verhalf. Endoaneurysmoraphie (Matas) und Umhüllung mit Folien wurden breit angewendet, bevor Ultraschalldiagnostik und Bypass-Chirurgie Routineverfahren wurden und die Prognose dramatisch verbesserten. Die diagnostischen und therapeutischen Probleme in der Mitte des 20. Jahrhunderts werden anhand von zwei prominenten Patienten dargestellt, Albert Einstein und Thomas Mann, die beide im Jahr 1955 an einer Aneurysmaruptur verstarben.
Rapamycin vermindert die Neointimaausbildung nach vaskulärer Schädigung
Authors: Hilker  , Buerke  , Guckenbiehl  , Schwertz  , Bühler  , Moersig  , Hake  , Oelert
Published: January 2006

Background: Proliferation and migration of vascular smooth muscle cells (SMCs) mark the key processes in the development of bypass graft disease and during neointima formation in restenosis after angioplasty. Growth factors are potent SMC mitogens as they are involved in SMC proliferation and in extracellular matrix (ECM) synthesis. Based on these premises, we examined the effect of the proliferation inhibitor rapamycin in human SMC culture and in a rabbit vascular injury model. Materials and methods: Injection of rapamycin or its vehicle was performed with an infusion-balloon catheter directly into the vessel wall during vascular injury. The intima/media ratio was determined histologically whereas the protein expression was analysed using the powerful two-dimensional gel electrophoresis (2D page) technique. Inhibition of proliferation after rapamycin application was estimated in a human SMC culture for time and dose dependent effects. Results: Rapamycin treatment resulted in a significant reduction of intima media ratio compared to vehicle treated animals after three weeks (0.65 ± 0.1 vs. 1.2 ± 0.2 intima-media-ratio, p < 0.05). 2D electrophoresis analysis proved increased ECM synthesis following angioplasty (i.e., lamin, vimentin) in vehicle treated animals. Local rapamycin administration resulted in profound reduction of ECM synthesis after vascular injury. In in-vitro experiments exposure of cultured human SMCs to rapamycin resulted in a significant and dose-dependent (1 nm–100 nm) reduction of human smooth muscle cell proliferation measured by cell counting. Conclusion: These above mentioned results suggest that protein synthesis in addition to reduction of cellular proliferation plays an important role following vascular injury, since application of rapamycin resulted in the reduction of SMC proliferation and ECM-synthesis.
Conservative therapy of acute embolic occlusion of the carotid bifurcation
Authors: Ernst  , Roedel  , Frauchiger
Published: January 2006

Embolische Verschlüsse der extrakraniellen Gefäße als Ursache eines zerebrovaskulären Insultes sind selten. Wir stellen zwei Patienten vor, bei denen es unter einer konservativen Behandlung mit Heparin zu einer spontanen Lyse mit Rekanalisation eines embolischen Verschlusses der Carotisbifurkation gekommen ist. Klinisch haben sich die Patienten von ihren zentral neurologischen Defiziten ohne Einschränkung in den täglichen Lebensverrichtungen erholt.
Verbesserung der Hautdurchblutung durch die transdermale Applikation von PGE1-Ethylesther bei systemischer Sklerodermie
Authors: Schlez  , Häfner  , Kittel  , Braun  , Diehm  , Jünger
Published: January 2006

Background: Patients with systemic scleroderma exhibit a noticeable slowing of blood cell velocities or even stasis in the capillaries of the skin. In this study the effects of transdermally applied prostaglandin PGE1 ethyl ester on nutritive cutaneous perfusion and on Raynaud’s symptoms were investigated. Patients and methods: 24 patients with systemic scleroderma were treated transdermally over a period of 14 days with prostaglandin E1 ethyl ester patches. The response of blood cell velocity in the nailfold capillaries to cold exposure was tested in 20 patients, and all of the patients recorded the number of Raynaud’s episodes in a journal over a period of two weeks. Results: After the transdermal application of prostaglandin E1 ethyl ester there was an increase in blood cell velocity in the nutritive capillaries of systemic scleroderma patients (increase from 0.35 ± 0.14 mm/s to 0.47 ± 0.11 mm/s, (p < 0.05)). At the same time there was a decrease in the number of Raynaud’s episodes (2.9 ± 2.4 per day to 2.6 ± 2.0 per day (p < 0.05)). Conclusion: The transdermal application of prostaglandin E1 ethyl ester was shown to have a favourable effect on nutritive blood flow in the capillaries of the skin in systemic scleroderma patients.
A rare case of Cannabis arteritis
Authors: Gröger  , Aslani  , Wolter  , Noah  , Pallua
Published: January 2006

Eine 24-jährige starke Cannabis Raucherin stellte sich mit progressivem Raynaud Syndrom und Fingerendgliednekrosen der rechten Hand vor. Rheumatologische Grunderkrankungen, Arteriosklerose und arterielle Embolien wurden ausgeschlossen. Eine Arteriographie ergab multiple Verschlüsse im Bereich des Unterarms, der Hand und der Finger mit Ausbildung von korkenzieherartigen Kollateralen. Basierend auf diesen angiographischen Befund konnte die Diagnose Cannabis-Arteritis gestützt werden. Nach operativer Nekrekomie, konservativer Wundbehandlung und Prostacyclintherapie zeigten die Fingerdefekte eine suffiziente Heilung. Die Grundlage für einen nachhaltigen Heilungsverlauf stellt jedoch der komplette Verzicht auf Cannabis- und Tabakprodukte dar.
Usefulness of tests to measure platelet function
Authors: Breddin  , Harder
Published: January 2006

Plättchenfunktionstests werden zur Erkennung einer angeborenen oder erworbenen Thrombozytenfunktionsstörung und zur Erfassung einer gesteigerten Plättchenaktivierung, die mit einer erhöhten Thromboseneigung einhergehen kann, verwendet. Plättchenfunktionstests werden auch zur Überwachung der Behandlung mit Thrombozytenfunktionshemmern wie Acetylsalicylsäure, Clopidogrel oder Plättchenmembran-Glycoprotein IIb/IIIa-Hemmern eingesetzt. Eine inkorrekte Blutentnahme ist der häufigste Fehler bei Untersuchungen der Plättchenfunktion. Globaltests sind neben der Plättchenzählung die Blutungszeit, die Thrombelastographie, der Plättchenfunktionsanalyser (PFA) und vielleicht in Zukunft das neue Impact®-System. Spezifische Tests messen die Thrombozytenausbreitung oder die Plättchenhaftung an definierten Oberflächen. Bei mehreren Verfahren werden die Thrombozyten vor und nach der Passage eines Filters gezählt. Einige dieser Tests sind teilweise standardisiert. Die Thrombozytenaggregation nach Gustav Born, ausgelöst durch ADP, Kollagen oder andere Substanzen, ist die am häufigsten bestimmte Plättchenfunktion. Einige neuere Methoden zur Aggregationsmessung werden beschrieben. Eine gesteigerte Plättchenaktivierung kann durch die Spontanaggregation (PAT) erfasst werden. Prospektive Untersuchungen haben gezeigt, dass die spontan gesteigerte Aggregation ein Risikofaktor bei Diabetikern für neue Gefäßverschlüsse und bei Gesunden für einen Herzinfarkt ist. Die Methode nach Wu und Hoak und die Messung von freigesetzten Thrombozyteninhaltsstoffen wie Plättchenfaktor 4 oder Betaglobulin sind nur von begrenztem Wert. Flowzytometrische Verfahren werden häufig angewendet um Aktivierungsmarker wie CD 62 und andere zu messen. Die Plättchen-induzierte Thrombinbildung ist eine wichtige Funktion zur Beurteilung von Medikamentenwirkungen. Keiner der heute verfügbaren Plättchenfunktionstests ist gut standardisiert. Hier sind weitere Anstrengungen erforderlich.
Die chirurgische Behandlung des M. Behçet
Authors: Ceyran  , Akçali  , Kahraman
Published: January 2006

Background: Vascular complications can be seen in patients with Behçet’s disease. Arterial and venous complications may be found separately or concomitantly in patients. Patients and methods: Out of 29 patients with vasculo-Behçet’s disease 7 patients with multiple aneurysms and venous lesions were documented over a period of 20 years. All patients were male, ranging in age from 24 to 52 years. The mean duration of the disease was 6 ± 2 years. The aneurysms were found in the following locations: one pulmonary artery, two abdominal aorta, four iliac, five femoral, and two popliteal artery. Both aneurysmal and occlusive lesions were present in three patients. In the venous lesions associated with the aneurysms there were three deep and three superficial venous thrombosis. Two patients had caval involvement-superior and inferior vena caval syndromes. Results: We performed seven interposition grafting by polytetrafloroethylene, one Y-grafting, one aneurysmorrhaphy, one lobectomy. Re-anastomosis was performed in two patients who had anastomotic aneurysms and graft occlusion without disabling ischemia. Venous pathologies were treated by medical therapy. The patients were followed up between 1 to 8 years. One of the patients with iliac artery aneurysm died due to gastrointestinal bleeding 15 months after the operation. Conclusions: In conclusion, when an aneurysm has been found in a patient with Behçet’s disease, the patient should be scanned for possible multiple aneurysms and venous lesions since they might be found together. Surgical treatment, when feasible, should be performed in cases with Behçet aneurysms because of a high risk of rupture. However, the possibility of an anastomotic aneurysm developing after surgery should also be kept in mind.
Venöse Anomalien in Zusammenhang mit Rekonstruktion von abdominellen Aortenaneurysmen
Authors: Papavassiliou  , Kakissis  , Dimitroulis  , Vorou  , Liapis
Published: January 2006

The coexistence of abdominal aortic aneurysm (AAA) and venous abnormalities is unusual. In this article two cases of AAA with concomitant anomalities of a retroaortic left renal vein and left-sided inferior vena cava are presented.
Die Fibrinogen-Adsorption – eine neue Therapieoption des Ulcus cruris venosum?
Authors: Stücker  , Moll  , Rudolph  , Robak-Pawelczyk  , Jünger  , Schultz-Ehrenburg  , Altmeyer
Published: January 2006

The initial element in the causation of venous ulceration is a disturbance of venous blood flow that leads to an increase in venous pressure. Eventually, however, it is the microcirculatory consequences of venous hypertension that lead to trophic skin changes and finally to ulceration. A reduction in blood viscosity results in an improvement at the microcirculatory level. The elimination of fibrinogen from plasma improves blood viscosity. This case report concerns a 75-year-old woman with venous ulcers of both legs (left lower leg: deep ulceration with a surface area of 3x5 cm; right lower leg: superficial, confluent ulceration with a total surface area of 5x10 cm). The patient underwent 20 sessions of fibrinogen adsorption, while simultaneously continuing with a regimen of conservative measures (activated charcoal cloth dressing with silver, calcium alginate dressings and short-stretch compression bandages). Following binding to a peptide (Gly-Pro-Arg-Pro-Lys), fibrinogen and fibrin were specifically removed from the patient’s plasma: her fibrinogen concentration was lowered from an original mean level of 310 mg/dl (SD ± 104 mg/dl) to 136 mg/dl (SD ± 54 mg/dl), and there was no return to the baseline concentration by the time of the next fibrinogen adsorption session. In response to this treatment the patient’s ulcers healed rapidly within 9 weeks. Dizziness and hematomas at the vascular access sites in both antecubital fossae were reported as adverse effects. A fall in hematocrit was also noted (before treatment 37% ± 1%; after treatment 35% ± 2%). This may have been caused by hemodilution due to the procedure and to cell losses during blood-plasma separation, a phenomenon that is known to occur during apheresis. This case report suggests that fibrinogen adsorption is low in adverse effects and is a useful addition to the range of treatments available for ulcers of venous etiology.
Mode of action of prostaglandin E1 in the treatment of peripheral arterial disease
Authors: Weiss
Published: January 2006

Obwohl Prostaglandin E1 vor 30 Jahren erstmals zur Therapie schwerer peripherer Durchblutungsstörungen eingesetzt wurde, ist der genaue Wirkmechanismus nicht bekannt. Die intraarterielle Anwendung von PGE1 induziert eine ausgeprägte Vasodilatation, die nach intravenöser Infusion nicht eintritt. Bei der nachgewiesenen klinischen Wirksamkeit von intravenös verabreichtem PGE1 kann die Vasodilation nicht als entscheidendes Wirkprinzip betrachtet werden. Multiple Effekte von PGE1 auf die korpuskulären Bestandteile des Blutes, Hämostase und Fibrinolyse sowie Endothel sind mittlerweile bekannt. In der vorliegenden Arbeit werden einige dieser Wirkmechanismen vorgestellt und diskutiert.
Fibromuscular dysplasia of the renal artery responsible for renovascular hypertension: a histological presentation based on a series of 102 patients
Authors: Vuong   , Desoutter  , Mickley  , Bültmann  , Rothenberger-Janzen  , Guyot  , Janzen
Published: January 2006

Background: Fibromuscular dysplasia (FMD) is a rare non-atherosclerotic and non-inflammatory disease in the arterial system. The purpose of the study was a retrospective analysis of FMD in the renal artery. Patients and methods: A total number of 102 patients (mean age: 36.9 years) who suffered from renovascular hypertension underwent a surgical therapy. The operative specimens of the renal arteries were analysed with the lightmicroscop using histological and immunohistochemical methods. Results: 101 patients (99.02%) presented a medial FMD (extensive-medial subtype in 56 patients, 54.9%, subadventitial subtype in 29 patients, 28.4% and combined subtype in 16 patients, 15.7%). In 1 patient (0.98%) an adventitial FMD was found. We observed the following complications: true and dissecting aneurysms (75 patients, 74.5%), arterio-venous fistulae (2 patients, 1.96%) and chronic thrombosis (10 patients, 9.8%). Conclusions: With the progress in angioplasty, not all patients suffering from FMD undergo a primary surgical therapy and therefore this lesion is less seen in the daily work of the histopathologist.
Severity of venous insufficiency is related to the density of microvascular deposition of PAI-1, uPA and von Willebrand factor
Authors: Kolbach  , Hamulyák  , Prins  , Neumann  , Cleutjens
Published: January 2006

Background: Impaired microcirculation in chronic venous insufficiency leads to chronic inflammation and dystrophic changes of the skin, and finally to leg ulceration. The purpose of this study was to investigate in more detail coagulation and fibrinolytic protein response of the capillaries in skin biopsies of the lower extremity. Patients and methods: From eighteen ambulant patients with venous leg ulcer(s) (n = 8) and controls (n = 10) with various degrees of venous insufficiency according to the CEAP classification, we obtained 4 mm punch biopsies. Immunohistochemical staining with tissue derived plasminogen activator (tPA), urokinase derived plasminogen activator (uPA), plasminogen activator inhibitor (PAI-1) and von Willebrand Factor (vWF) was performed and analyzed with bright field microscopy. Results: The amount of staining with vWF (p = 0.04) and uPA (p = 0.02) showed statistically significant differences, PAI-1 (p = 0.09) and tPA (p = 0.50) showed no difference between leg ulcer and control groups. A strong proliferation of capillaries with tortuous capillary loops in the papillary dermis was seen, but no statistically significant difference (M-W test, p = 0.10) was found between the groups. Comparison between CEAP classes 0–6 showed a statistically significant increased staining pattern of vWF (p = 0.06), uPA (p = 0.02) and PAI-1 (p = 0.02), but not from tPA (p = 0.30). Conclusions: In skin biopsies of the lower extremity of patients with severe venous insufficiency increased deposition of vWF, PAI-1 and uPA were found in the capillaries. These findings point to a local imbalance in coagulation and fibrinolytic status, which might contribute to impaired microcirculation and finally to the development of venous leg ulceration.
Transperitoneal versus retroperitoneal approach for treatment of infrarenal aortic aneurysms: Is one superior?
Authors: Wachenfeld-Wahl  , Engelhardt  , Gengenbach  , Bruijnen  , Loeprecht  , Woelfle
Published: January 2006

Background: As endovascular treatment of asymptomatic infrarenal abdominal aortic aneurysm (AAA) increasingly competes with surgical repair, it is necessary to optimize the surgical technique. The aim of this study was therefore to evaluate the superiority of either retroperitoneal (RP) or transperitoneal (TP) approach. Patients and methods: Intra- and peri-operative data from 80 patients with infrarenal AAA and tube graft repair were analysed retrospectively. The RP-approach was used in 37 patients and in 43 the transperitoneal. Results: There was no relevant difference in demographic data and anaesthetic regime; exceptions were differences between the two groups in terms of age (median RP 72.31 vs. TP 68.58 years, p = 0.0174), hypertension (RP 26/37 vs. TP 40/43, p = 0.0019), smoking (RP 25/37 vs. TP 38/43, p = 0.0462), pulmonary diseases (RP 15/37 vs. TP 7/43, p = 0.0232), and previous abdominal surgery (RP 3/37 vs. TP 12/43, p = 0.042). No patient died during the first 30 post-operative days. The RP-group had a longer cross-clamping time (median RP 50 vs. TP 45 min, p = 0.0115) but no difference was found in operating time. Intra-operative blood loss was higher in the RP-group (median RP 800 vs. TP 500 ml, p = 0.033) with an increased need for blood substitutes (median RP 1 vs. TP 0 packed red cells, p = 0.0068). Time spent in ICU was shorter (median RP 24 vs. TP 46 hours, p = 0.0104), but duration of hospitalisation was longer for the RP-group (median RP 13 vs. TP 10.5 days, p = 0.0156). No differences were found in the need for analgesics, the frequency of procedure related complications, and post-operative recovery. Conclusions: Surgical repair of AAA in selected patients by tube graft placement is a safe procedure independent of the approach. In particular, our findings do not support previously reported superiority of the RP-approach.
Symptomatic vascular complications after vascular closure device use following diagnostic and interventional catheterisation
Authors: Thalhammer  , Aschwanden  , Jeanneret  , Labs  , Jäger
Published: January 2006

Background: Haemostatic puncture closure devices for rapid and effective hemostasis after arterial catheterisation are a comfortable alternative to manual compression. Implanting a collagen plug against the vessel wall may become responsible for other kind of vascular injuries i.e. thrombotic or stenotic lesions and peripheral embolisation. The aim of this paper is to report our clinically relevant vascular complications after Angio-Seal® and to discuss the results in the light of the current literature. Patients and methods: We report the symptomatic vascular complications in 17 of 7376 patients undergoing diagnostic or therapeutic catheterisation between May 2000 and March 2003 at the University Hospital Basel. Results: Most patients presented with ischaemic symptoms, arterial stenoses or occlusions and thrombotic lesions (n = 14), whereas pseudoaneurysms were extremely rare (n = 3). Most patients with ischaemic lesions underwent vascular surgery and all patients with a pseudoaneurysm were successfully treated by ultrasound-guided compression. Conclusions: Severe vascular complications after Angio-Seal® are rare, consistent with the current literature. There may be a shift from pseudoaneurysms to ischaemic lesions.
Konservative befundadaptierte Therapie von superinfizierten chronischen venös bedingten Ulcera cruris
Authors: Billmann  , Köhler  , Varelas  , Mayer
Published: January 2006

Die erfolgreiche Therapie von venösen Ulzera stellt eine besondere klinische Herausforderung dar. Das im Folgenden beschriebene konservative Wundmanagement bei einem Hochrisikopatienten zeigt eine Alternative zur primären operativen Therapie auf. Ein 79-jähriger, multimorbider Patient in reduziertem Allgemeinzustand wird mit superinfizierten, nekrotisch veränderten und schmerzhaften Ulzera hospitalisiert. Aufgrund der Multimorbidität des Patienten ist die kausale operative Therapie der zugrunde liegenden venösen Insuffizienz, bestehend aus Stripping der Vena saphena magna mit Perforantenligatur, kontraindiziert. Es wird deshalb interdisziplinär die Indikation für eine konservative Therapie gestellt. Sie umfasst ein initiales lokales Debridement, Feuchtverbände, Kompressionstherapie, systemische Antibiose und analgetische Therapie, unterstützt durch die allgemeine Stabilisierung des Patienten. In regelmäßigen Abständen wird eine fotografische Wunddokumentation durchgeführt. Der Behandlungs- und Beobachtungszeitraum beträgt 63 Tage. Durch konservatives Wundmanagement wird eine deutliche Besserung der Wundverhältnisse sowie des Allgemeinzustandes des Patienten erzielt. Die Dauer des Verbandswechsels kann von 2 Stunden auf 30 Minuten verkürzt werden. Der Schmerzscore reduziert sich von 8/10 auf 4/10 bei abnehmendem Analgetikabedarf. Die fotografische Dokumentation zeigt eine deutliche Progredienz der Wundheilung innerhalb von 9 Wochen auf. Unter antibiotischer Therapie und konservativem Wundmanagement sind die erhöhten Entzündungsparameter rückläufig. Durch ein konservatives, befundadaptiertes Therapieregime werden superinfizierte, chronische venös bedingte Ulzera in einen stabilen Zustand überführt.
Treatment costs and quality of life of patients with peripheral arterial occlusive disease – the German perspective
Authors: Holler  , Claes  , von der Schulenburg
Published: January 2006

Background: To objectify the debate about the restricted resources of the health system, examinations about the treatment costs and quality of life implications of different illnesses are necessary. The aims of the examination were the quantification of costs that are caused by a patient with PAD per year and the determination of the quality of life. Patients and methods: 280 patients (mean 66.6 years) in Fontaine stages II to IV were included in the study to determine their treatment costs for the year 2001 retrospectively from patient records. Health-related quality of life was recorded through the standardized questionnaires PAVK-86, SF-36 and EQ-5D. Results: A patient with PAD in stage IIa costs on average 1792.45 Euro, in stage IIb 2551.28 Euro, in stage III 4356.48 Euro and in stage IV 6225.89 Euro. The costs of the in-hospital treatment dominated the total result on average with 44.4% of the direct costs. Further cost factors were the drugs with 33.4%, the out-patient medical treatment with 9.9%, the expenditures for care with 6.7%, rehabilitation with 3.6% and adjuvants with a share of 1.9%. The indirect costs played a subordinate role with 9.67% of the total costs. The quality of life was clearly restricted in all stages of the PAD. The quality of life especially was strongly decreased from the Fontaine stage IIb on. The problems were mainly in the areas of the physical functions and pain. Conclusion: The study showed that the treatment of patients with PAD is very cost-intensive and that patients have to suffer from a considerable loss of quality of life.
Time for a new classification of femoral artery aneurysm?
Authors: Amer  , Grocott  , Shami
Published: January 2006

It has been over 30 years now since the original classification of femoral artery aneurysms by Darning and Cutler to type 1 and 2. We have demonstrated in a case report that it is time for amendment of this classification. Isolated profunda aneurysm do exist as separate entity, and they can be managed by complete exclusion from the circulation provided the presence of patent superficial femoral artery and good runoff circulation, without any ill effects.
New insights into the pathogenesis of diabetic retinopathy – hormonal rather than metabolic factors are important
Authors: Chantelau  , Volaco  , Meyer-Schwickerath
Published: January 2006

Diabetic retinopathy has traditionally been viewed as a metabolite-driven, occlusive vasculopathy that affects both retinal microvascular haemodynamics and structure; analogies to cholesterol-driven occlusive atherosclerosis of the macrovascular circulation were drawn. However, this paradigm may no longer be appropriate. Recent evidence suggests that diabetic retinopathy from the beginning is the consequence of a complex hormonal dysfunction, which is related to insulin-dependent up- and downregulation of growth factors, to which metabolic, haemodynamic, endocrine, paracrine, and autocrine mechanisms contribute.
The cuff width influences the toe blood pressure value
Authors: Påhlsson  , Jörneskog  , Wahlberg
Published: January 2006

Background: Toe blood pressure is a valuable and often used parameter when lower limb ischaemia is evaluated in patients with diabetes, but little has been done to standardise the method. The aim of this study was to evaluate if the cuff size influences the toe blood pressure values obtained in patients with diabetes. Patients and methods: Eleven patients with diabetes without a history of peripheral vascular disease, and six age matched healthy subjects were investigated. Their blood pressures were measured in the upper arm and at the ankle level repetitively. For measurement of toe blood pressure two different cuff widths were used. Results: All blood pressures were similar in patients and control subjects, as well as over time. The toe blood pressure values were 18 mmHg higher (p < 0.01) if measured with a 2.0-cm compared to a 2.5-cm wide cuff. There was a relationship (r = 0.63, p < 0.05 for patients) between toe circumference and the toe blood pressure value, where smaller halluxes gave lower values. Conclusions: The cuff width influences the obtained toe blood pressure value and needs to be considered when evaluating limb ischemia in patients with diabetes.
Progress of local symptoms of superficial vein thrombosis vs. duplex findings
Authors: Górski  , Noszczyk  , Kostewicz  , Szopinski  , Kielar  , Michalak  , Marianowska  , Wilkowski
Published: January 2006

Background: Risk of subsequent deep vein thrombosis (DVT) following superficial vein thrombosis (SVT) is not fully appreciated. Mechanisms, time relations and risk factors for DVT arising upon earlier SVT remain unclear. The aim of this study was to analyze time relations between local symptoms of lower limb superficial vein thrombosis, duplex findings and onset of deep vein thrombosis during clinically evident course of SVT. Patients and methods: 46 patients with early (onset less than 72 hours prior to inclusion) clinical diagnosis of SVT, confirmed ultrasonographically were included in this prospective, multicenter study. Progress of pain, erythema and swelling in relation to subsequent ultrasound changes in size and localization of thrombus at 0, 7, 14 and 21 day of study has been recorded. Results: Local symptoms subsided completely during 3 weeks. At that time thrombus disappeared completely only in 26% of cases, in remaining cases decreased in size from average 117.5 mm to 43.0 mm. Thrombus regression was similar to venous blood outflow direction – proximal to femoral area. Thrombus propagation was observed following regression of local symptoms of SVT. 4 cases of DVT (8.7%) were diagnosed at 2–11 days. Conclusions: Local, clinically detectable symptoms of SVT regress incomparably quicker than thrombus in affected veins. Risk of further thrombus propagation extends well beyond the period of intensive local symptoms of SVT. Regression of thrombus in femoral area requires significantly more time than in popliteal or calf segment. Thrombus propagation is directed with blood flow towards femoral segment.
Transbrachial angiography: an effective and safe approach
Authors: Basche  , Eger  , Aschenbach
Published: January 2006

Background: Description of the technique of the transbrachial catheter diagnostics, retrospective evaluation of the technical success rate and the complications. Patients and methods: In a period of 8 years the transbrachial approach was used in 2555 patients, 1734 men and 821 women with an average age of 62.9 years. The investigation was done with outpatients in approximately 90% of the cases. Usually, the preferred arm was not punctured. For the diagnostics F4 and F5-catheter sheaths and selective catheter and/or plain catheters were used. Results: 12 times (0.47%) the investigation did not succeed technically. The image quality of the vascular representations was diagnostically sufficient. The total complication rate amounted to 0.47%. The following complications appeared: four dissections in the site of puncture, one embolism into arteries at the forearm, three transitory ischemic attacks, four haematoma at the site of puncture. Conclusions: The transbrachial catheter diagnostics is a little invasive, efficient and low-risk method, which is practicable in out-patients.
A severe case of systemic lupus erythematosus with cerebral involvement
Authors: Wiedmann  , Seidel  , Mende  , Petros  , Engelmann
Published: January 2006

We describe an 18-year-old girl who presented with severe systemic lupus erythematosus with multiple organ involvement. The disease was further complicated by recurrent seizures and intracerebral left parieto-occipital bleeding that required neurosurgical treatment. Postoperative rebleeding occurred due to disseminated intravascular coagulation and platelet dysfunction. Catastrophic antiphospholipid syndrome was suspected, but could not be confirmed during follow-up. Additional treatment with plasmapheresis and intravenous pulse cyclophosphamide in combination with corticosteroids was started. Liquor drainage via a ventriculo-peritoneal (vp)-shunt was necessary because of a hydrocephalus malresorptivus. The patient's recovery was slow and incomplete (cachexia and amaurosis persisted). Follow-up was further complicated by an intraperitoneal vp-shunt cyst, which was initially treated conservatively, but finally had to be revised operatively.
Successful treatment of stasis dermatitis with topical tacrolimus
Authors: Dissemond  , Knab  , Lehnen  , Franckson  , Goos
Published: January 2006

Stasis dermatitis is a common dermatologic disorder, as a consequence of impaired venous drainage and often accompanied by chronic leg ulcers. Until today the standard in acute therapy represents the topical administration of highly potent corticosteroids and if possible a consequent long-term compression therapy. The macrolide tacrolimus represents a new selective inflammatory cytokine release inhibitor by binding to macrophilin-12 and inhibiting calcineurin. Beside the resulting anti-inflammation and immunosuppression an antipruritic effect have been discussed as further clinical benefits of tacrolimus. Here we report for the first time about a 81-year old patient suffering from an ulcus cruris mixtum and stasis dermatitis treated with topical 0.1% tacrolimus ointment twice daily for 5 days. Until now tacrolimus is available for topical treatment as a fatty ointment only. Although we would have preferred a more hydrophilic base for treatment of acute stasis dermatitis we achieved complete healing. As this is only a case report about one single patient further clinical investigations are needed to confirm this observation in more individuals with stasis dermatitis.