Accelerated thrombolysis and angioplasty for hand ischemia in Buerger's disease

A patient with severe hand ischemia due to Buerger's disease was treated by a rapidly effective modification of percutaneous catheterization. Accelerated mechanical and pharmacologic thrombolysis of an occluded palmar arch with 200,000 U urokinase and subsequent small vessel angioplasty abolished pain and restored digital perfusion within 40 min.     

Effect of therapy on 24-h subcutaneous blood flow in the leg in patients with severe ischemia

The effect of vascular surgical reconstruction or Buerger's exercises upon average subcutaneous blood flow for a 24-h period was studied in 14 patients with severe leg ischemia due to occlusive arterial disease. Blood flow was estimated proximally in the calf and in the foot by a 133Xe washout technique. Seven patients underwent vascular surgery. Postoperatively subcutaneous blood flow increased in the calf and the foot in all patients except one in whom a decrease in blood flow in the foot was seen. In this case a decrease in systolic blood pressure occurred following the operation. Buerger's exercises did not alter subcutaneous blood flow either in the calf or in the foot in the seven patients studied. Buerger's exercises seem to be of no value for these patients. The measurement of blood flow in subcutaneous tissue over a period of 24 h seems to be a useful test of the effect of different treatments.     

Effect of therapy on 24-h subcutaneous blood flow in the leg in patients with severe ischemia

The effect of vascular surgical reconstruction or Buerger's exercises upon average subcutaneous blood flow for a 24-h period was studied in 14 patients with severe leg ischemia due to occlusive arterial disease. Blood flow was estimated proximally in the calf and in the foot by a ¹³³Xe washout technique. Seven patients underwent vascular surgery. Postoperatively subcutaneous blood flow increased in the calf and the foot in all patients except one in whom a decrease in blood flow in the foot was seen. In this case a decrease in systolic blood pressure occurred following the operation. Buerger's exercises did not alter subcutaneous blood flow either in the calf or in the foot in the seven patients studied. Buerger's exercises seem to be of no value for these patients. The measurement of blood flow in subcutaneous tissue over a period of 24 h seems to be a useful test of the effect of different treatments.     

Emergent Treatment of Acute Embolic Superior Mesenteric Ischemia with Combination of Thrombolysis and Angioplasty: Report of Two Cases

We successfully revascularized the acutely occluded superior mesenteric artery (SMA), caused by a thromboembolus, with a combination of thrombolysis and percutaneous transluminal angioplasty (PTA) in 2 patients. Considerable percent luminal reduction (>90%) was still observed after thrombolysis in both patients. Subsequent adjunctive balloon angioplasty produced sufficient luminal diameter of the SMA (<20% luminal reduction). No serious acute procedural complication occurred. The time from onset to partial reperfusion by thrombolysis was approximately 4.5 and 5.5 hours. Approximately 1 week after the combination therapy, colonoscopy and a small bowel radiocontrast series showed localized mucosal ischemia with mild erosions and ulcerations in the terminal ileum and ascending colon in 1 patient. Subsequent bowel resection was required but the resection was short (<20 cm). The other patients bowel condition was good and did not require any surgical treatment. The present cases suggest that combination therapy is useful for achieving rapid and sufficient revascularization of acute proximal thromboembolic SMA occlusion, and prevents the considerably broad bowel necrosis that requires surgical bowel resection, resulting in short bowel syndrome.     

血管成形联合置管溶栓治疗下肢动脉硬化闭塞症的临床效果研究

目的：比较血管成形联合置管溶栓治疗与常规血管成形术治疗下肢动脉硬化闭塞症的临床效果。 方法：选择2014年1月至2015年12月我院收治的下肢动脉硬化闭塞症患者33例,18例行常规介入治疗（常规组）,15例行介入联合溶栓治疗（溶栓组）,观察两组患者的踝肱指数（ABI）、血管开通率、临床疗效与并发症,随访其血管通畅情况。 结果：常规组的血管开通率、临床有效率均为88.89%（16/18）,溶栓组分别为93.33%（14/15）、100%（15/15）。两组的术后足背动脉搏动均增强,ABI值均较术前明显升高,其中溶栓组ABI提高幅度较常规组大,组间差异有统计学意义（P<0.05）。常规组发生血栓相关并发症2例,溶栓组无相关并发症出现。常规组术后3、6、12、24个月血管通畅率分别为83.33%（15/18）、83.33%（15/18）、72.22%（13/18）及62.50%（10/16）,溶栓组分别为100%（15/15）、100%（15/15）、80.00%（12/15）及71.43%（10/14）。溶栓组血管通畅率数值高于常规组。 结论：经皮血管成形联合置管溶栓治疗下肢动脉硬化闭塞症的临床效果优于常规的血管成形术。     

介入治疗肺动脉栓塞疗效探讨

目的：评价介入溶栓球囊扩张术对肺动脉栓塞治疗的效果。方法：8例肺动脉栓塞患者,经股静脉穿刺插管。导管导丝置于肺动脉内进行碎栓,采用尿激酶冲击溶栓、球囊扩张术和24h持续灌注溶栓,同时给予肝素抗凝治疗。结果：完全开通3例,部分开通5例;3例氧分压均达到100％,5例氧分压在93％以上。结论：介入治疗肺动脉栓塞能及时开通肺动脉,恢复肺动脉血供,纠正低氧血症,是治疗肺动脉栓塞一种有效的方法。     

Arterial changes after thrombolysis and percutaneous transluminal angioplasty in vertebrobasilar thrombosis.

We present clinicopathologic findings in a patient treated with intraarterial thrombolysis and angioplasty for vertebrobasilar thrombosis. Autopsy revealed a marked inflammatory infiltrate within the vertebral artery at the site of catheter manipulation. This finding may have important implications for the use of interventional angiography in cerebrovascular disease.     

经桡动脉途径介入治疗髂动脉股动脉硬化闭塞症

目的 回顾性分析经桡动脉途径介入治疗髂动脉股动脉硬化闭塞症的安全性及其临床疗效.方法 经桡动脉途径介入治疗16例复杂髂动脉股动脉硬化性闭塞症患者,病程3 d至2年.所有患者均合并静息痛,间歇性跛行距离小于500 m,单侧病变9例、双侧病变7例,术前踝肱指数0～0.57(0.32±0.14).髂动脉股动脉完全闭塞6例,其余10例狭窄程度＞75%.留置导管于血栓内或其上方持续滴注尿激酶,如果溶栓72 h没有效果,停止溶栓.血栓溶解后,对残余狭窄程度＞50%的患者给予球囊、支架成形术.比较手术前、后患者的症状及踝肱指数变化,结果采用配对t检验.结果 16例患者溶栓时间3.0～15.0(8.4±2.9)d,15例血管再通.16例患者静息疼痛症状消失;4例仍有间歇性跛行,距离均大于500 m,与术前相比踱行距离明显延长;术后踝肱指数为0.63～1.10(0.91±0.12),较术前明显升高(t=21.73,P＜0.01).随访时间6～24个月,随访期间症状复发1例,再次介入治疗成功.所有患者未发生手术相关严重并发症.结论 经桡动脉途径长时间连续溶栓联合球囊扩张以及支架成形术治疗髂动脉股动脉硬化闭塞症,安全性高、患者耐受性好,是经股动脉途径介入治疗的补充,尤其对于复杂的双侧髂动脉股动脉病变的介入治疗具有更大的优势.     

髋关节区动脉支架植入治疗下肢动脉重症缺血的临床效果评价

目的观察与评价髋关节区支架植入治疗下肢动脉重症缺血的安全性、有效性及对股深动脉血流的影响。 方法66例动脉硬化闭塞所致下肢重症缺血患者（共70条动脉,均累及股总动脉和/或股动脉近心段）。平均年龄74.6岁。男46例,女20例。左下肢动脉40条,右下肢动脉30条。开通闭塞动脉后,行球囊扩张及支架植入。 结果术中股动脉急性闭塞3例（局部溶栓后获得通畅）,余下肢动脉即刻血流均获得通畅,下肢缺血症状均明显改善。术后15例患肢出现血流过度灌注,无严重并发症发生。随访54例（失访12例）,随访时间2～30个月,平均（16.2±2.6）个月。25例因再狭窄或闭塞发生患肢缺血,其中16例接受再次介入治疗（PTA及导管溶栓后获二次通畅）。跨髋关节支架均无断裂,股深动脉均仍保持通畅。6例发生心、脑血管意外,其中2例死亡。 结论跨髋关节动脉支架植入可安全、有效地改善下肢动脉重症缺血,且不影响股深动脉血流。     

Comparative Efficacy of Pulse-Spray Thrombolysis and Angioplasty Versus Surgical Salvage Procedures for Treatment of Recurrent Occlusion of PTFE Dialysis Access Grafts

Purpose: To compare the efficacy of surgery versus pulse-spray thrombolysis and angioplasty in patients with recurrent thrombosis of polytetrafluoroethylene (PTFE) dialysis access grafts. Methods: We analyzed 96 consecutive interventions for thrombosed PTFE dialysis access grafts in 18 patients. Primary patency after thrombolysis and angioplasty (n= 25) was compared with primary patency following thrombectomy alone (n= 50) or thrombectomy followed by graft revision (n= 21) using life-table analysis. A Cox proportional hazards model that accounted for graft age and number of previous interventions was used to generate the relative risk for recurrent occlusion following therapy. Results: Life-table analysis showed that patency after thrombolysis and angioplasty was greater than that following thrombectomy alone (p= 0.02). After accounting for the age of the graft and the number of previous interventions (average six per patient), the relative risk for recurrent occlusion [3.0; 95% confidence intervals (CI): 1.5, 6.4] was greater for thrombectomy alone than for thrombolysis/angioplasty [0.6; CI = 0.3, 1.3]. The relative risks of repeat occlusion following thrombolysis/angioplasty [0.6; CI = 0.3, 1.3] and thrombectomy/surgical revision [1.0; CI = 0.5, 1.7] were similar. Conclusion: Outcome data from our retrospective study on recurrent thrombosis of PTFE dialysis access grafts suggest that thrombolysis/angioplasty is superior to thrombectomy alone, and equivalent to thrombectomy/surgical revision.     

Economic analysis of clinical positron emission tomography of the heart with rubidium-82

This report describes a cost analysis for clinical positron emission tomography (PET) of the heart using generator produced rubidium-82 (82Rb). Considered sequentially are the clinical problem, current noninvasive radionuclide methods, positron emission tomograph, and the cost of PET per study. Also analyzed are the costs of PET versus thallium imaging in the management of chest pain, for screening asymptomatic men at high risk for coronary artery disease and for evaluating myocardial viability after myocardial infarction or thrombolytic therapy. Noninvasive assessment of coronary artery stenosis and myocardial ischemia/viability in symptomatic or asymptomatic subjects remains a major medical problem because the sensitivity and specificity of thallium imaging are only 70-85% and 50-70%, respectively, in recent studies. Cardiac positron imaging has an accuracy for noninvasive diagnosis of coronary artery disease in symptomatic or asymptomatic patients with a sensitivity and specificity of 95-98%. It can also be used for assessing physiologic stenosis severity, for imaging myocardial infarction and viability, for assessing effects of interventions such as thrombolysis, percutaneous transluminal coronary angioplasty (PTCA) or bypass surgery on myocardial perfusion, metabolism or coronary flow reserve, for assessing collateral function noninvasively in man, and for diagnosing cardiomyopathy not due to coronary artery disease. Although the cost for cardiac PET with 82Rb may be modestly higher than for 201Tl, the greater diagnostic yield of PET results in comparable or lower overall medical management costs than no diagnostic tests/interventions and lower overall costs compared to thallium imaging for evaluating patients with chest pain, asymptomatic high risk males, and patients after acute myocardial infarction/thrombolysis for myocardial viability.     

Intracranial balloon angioplasty of acute terminal internal carotid artery occlusions

Acute embolic occlusion of the intracranial internal carotid bifurcation is associated with a poor prognosis. Recanalization rates of this lesion with intravenous or intraarterial thrombolysis are exceedingly low. We describe the use of balloon angioplasty after failed thrombolysis to achieve immediate recanalization of acute carotid T occlusions in two patients. At 1-month follow-up, both patients were alive with neurologic deficits. For acute carotid T occlusion, balloon angioplasty should be considered a first-line endovascular therapy.     

Initial results of reteplase in the treatment of acute lower extremity arterial occlusions

PURPOSE: To assess the feasibility and efficacy of reteplase in transcatheter arterial thrombolysis for lower extremity occlusive disease. MATERIALS AND METHODS: Fifteen consecutive patients with acute lower extremity ischemia due to occlusive disease were treated by means of catheter-directed thrombolysis with reteplase. Following diagnostic angiography, thrombolysis was started either from an antegrade puncture site in cases of femoropopliteal occlusions, or from the contralateral groin in cases of thrombosis of the iliac artery, common femoral artery, or infrainguinal bypass grafts. Reteplase was infused at a rate of either 0.5 U/h (six patients) or 1.0 U/h (nine patients). RESULTS: Complete thrombolysis was achieved in all of the nine (100%) patients in the 1.0 U/h group and in four of six (66%) patients in the 0.5 U/h group for a combined success rate of 13 of 15 (87%). Clinical success was achieved in 11 of 15 patients overall (73%). Major bleeding complications occurred in none of the 9 patients in the 1.0 U/h group and in one (16%) of the six patients in the 0.5 U/h group for an overall rate of 6%. CONCLUSIONS: Reteplase shows promise as an alternative to urokinase in the treatment of lower extremity ischemia due to arterial occlusive disease.     

Accelerated thrombolysis facilitated by direct puncture of occluded prosthetic femoral grafts.

Inability to access occluded grafts is a major limitation to successful thrombolysis and may even preclude it. This paper addresses the problem and offers a new technique of direct puncture of prosthetic grafts through which thrombolysis and angioplasty can be performed. These techniques resulted in accelerated thrombolysis in all 15 patients studied with no failures due to inability to attain graft access.     

Pharmacomechanical thrombolysis and angioplasty in the management of clotted hemodialysis grafts: early and late clinical results.

The results of pharmacomechanical thrombolysis and angioplasty of 121 thrombosed hemodialysis grafts were reviewed. The initial pharmacomechanical method (used in 65 cases) employed clot maceration with hook-shaped catheters and clot lacing with highly concentrated urokinase. The current technique (used in 56 cases) consisted of pulsed-spray injection of urokinase into the clot. All fully treated grafts (117 cases) underwent complete or near-complete thrombolysis, and 93% remained patent after 1 day. Mean time for pulsed-spray lysis was 46 minutes +/- 21. One patient (less than 1%) had gastrointestinal bleeding and received a transfusion; minor complications occurred in 3% of patients. Primary and secondary graft patency rates for both methods at 1 year were 26% and 51%, respectively. While graft age and results of angioplasty did not influence future graft patency, shorter intervals between graft thromboses was predictive of earlier subsequent graft failure. Results suggest that pharmacomechanical thrombolysis and angioplasty provide rapid, consistent, and safe recanalization of clotted hemodialysis grafts and represent a promising additional therapeutic approach to long-term graft management.     

Percutaneous transluminal angioplasty adjunct to thrombolysis for acute middle cerebral artery rethrombosis.

PURPOSETo report three patients, each of whom had acute rethrombosis of a reopened middle cerebral artery after urokinase treatment for proximal stenosis (percutaneous transluminal angioplasty of the stenosis was performed adjunctive to the thrombolytic treatment to preserve the success of the thrombolysis), and a fourth patient who had percutaneous transluminal angioplasty right after the completion of thrombolysis and had no rethrombosis despite a partial dilatation of the severe stenosis.METHODSThrombolytic treatment was carried out by a coaxial technique with a Tracker 18 catheter through a 5-F angiographic catheter; 80,000 U in 5 mL of urokinase were intermittently injected every 15 minutes after an initial dose of 250,000 U. All patients were given 3000 U of heparin with a booster dose of 1000 U every hour. Angioplasty was performed with a Stealth catheter balloon, 2 to 3 mm x 1.5 cm.RESULTSThree patients recovered without hemorrhage after percutaneous transluminal angioplasty and thrombolytic treatment. Percutaneous transluminal angioplasty was unsuccessful in one patient because of the inability to pass a 2-mm Stealth balloon catheter, and the result was a second rethrombosis. This patient had a poor recovery.CONCLUSIONAcute thrombosis of the middle cerebral artery may be associated with severe proximal stenosis. Rethrombosis may occur even after complete thrombolysis. Percutaneous transluminal angioplasty may be safely performed to prevent rethrombosis.     

介入治疗肝移植术后肝动脉并发症的初步经验

目的总结采用介入方法治疗肝移植术后并发肝动脉狭窄及血栓形成的初步经验。方法对4例肝移植术后并发肝动脉狭窄或血栓形成的患者行球囊扩张、经动脉溶栓、内支架置入术。结果1例肝动脉狭窄的患者经球囊扩张后临床症状缓解;3例肝动脉血栓形成患者经动脉溶栓后即刻肝动脉血流得到恢复;1例患者溶栓后3d发生吻合口出血,置入带膜支架,症状缓解,1d后肝动脉再次闭塞,2周后行第2次肝移植。结论采用介入方法对肝移植术后并发肝动脉狭窄或血栓形成的患者进行治疗是可行的,但必须谨慎实施,以避免发生出血等并发症。     

Thrombosed dialysis grafts: efficacy of intrathrombic deposition of concentrated urokinase, clot maceration, and angioplasty

Forty-one thrombosed polytetrafluoroethylene hemodialysis grafts in 26 patients were treated by a modified method of fibrinolytic therapy and transluminal angioplasty. The modifications included the use of highly concentrated urokinase, intrathrombic injection of urokinase into mechanically macerated thrombi, use of a crossed two-catheter technique, observation of the patient in the angiography suite during the entire procedure, and transluminal angioplasty to correct underlying stenosis immediately after partial or complete thrombolysis. Lysis was initially successful in 37 (90%) of 41 procedures. Successful treatment, defined as a functional graft for longer than 6 months without intervening surgery, was achieved in 16 (62%) of 26 patients. In comparison with previous transluminal or surgical regimens, this modified method permits marked acceleration of thrombolysis, immediate transluminal angioplasty, and sparing of potential future graft sites.     

Stent implantation for acute iliac artery occlusions: initial experience

PURPOSE: Treatment options for acute occlusion of the iliac arteries include surgical thrombectomy, surgical bypass, and endovascular interventions such as thrombolysis and mechanical thrombectomy with or without adjunctive angioplasty or stent implantation. Acute lesions are not usually treated by stent implantation for fear of distal embolism. The purpose of this study was to retrospectively review a single-center experience of primary iliac stent implantation for acute ischemia secondary to acute thrombosis. MATERIALS AND METHODS: Between April 2004 and August 2005, seven patients (five men and two women; mean age, 69.9 y; range, 53-93 y) underwent iliac stent implantation for the acute onset (within 12 days before presentation) of ipsilateral ischemic symptoms. Diagnostic angiography revealed occlusion of the common and external iliac arteries (n = 3) or external iliac artery (n = 4). Patients with rest pain (n = 6) were treated with unfractionated heparin. RESULTS: All acute occlusions were traversed by the guide wire with relative ease. Recanalization with stent implantation was successful in all cases without distal embolization. Five patients showed noticeable clinical improvement. Two elderly patients with isolated patent profunda segments with no demonstrable distal runoff vessels did not have long-term clinical improvement despite successful iliac recanalization. CONCLUSIONS: This small case series suggests that primary stent implantation for acute iliac occlusions with a patent common femoral artery under intravenous heparin protection may be a reasonable endovascular alternative to thrombolysis for patients who cannot tolerate the time delay to achieve thrombolysis or who have contraindications to thrombolysis. The safety of this technique may be comparable to that of primary stent implantation for chronic occlusions, but larger series would be necessary to confirm this.     

Endovascular Venous Thrombolysis in Children Younger than 24 Months

PurposeTo evaluate the technical feasibility and safety of percutaneous endovascular thrombolysis for extremity deep venous thrombosis (DVT) in children < 24 months old.Materials and MethodsA retrospective chart review of a clinical and imaging database was performed for pediatric patients who underwent endovascular therapy for DVT between January 2010 and July 2013. Indications, techniques, technical and clinical success, and complications were reviewed. Techniques for thrombolysis included catheter-directed therapy (CDT) using alteplase infusion via a multi–side hole catheter, mechanical thrombectomy, and angioplasty. Short-term outcomes were assessed using surgical and imaging follow-up examinations for patency of the targeted vessel. Patients included 11 children (mean age, 9 mo; range, 3 wk–23 mo) who consecutively underwent endovascular thrombolysis for upper extremity (n = 6) or lower extremity (n = 5) DVT. The most common indication was preservation of venous access for future cardiac surgery or medical therapy.ResultsThe most common risk factor was the presence of a central venous catheter (10 of 11 patients). All patients with upper extremity DVT had congenital heart disease. CDT and angioplasty were performed in all patients. Venous patency was established in all patients. A grade III (95%–100%) thrombolysis response was achieved in seven patients, and a grade II (50%–95%) thrombolysis response was achieved in four patients. A major complication of pulmonary embolism occurred in one patient with upper extremity thrombolysis and was managed by intravenous systemic alteplase and heparin. No recurrence of thrombosis was found on average follow-up of 11.8 months (range, 1–41 mo).ConclusionsPercutaneous endovascular thrombolysis for extremity DVT is safe and technically feasible in children < 24 months old.