Selective thrombolysis with low-dose urokinase in chronic arteriosclerotic obstructions

Twenty-one patients, 15 males and 6 females aged 52–75 years, with angiographically demonstrated occlusions of the superficial femoral or popliteal arteries, were treated by low-dose urokinase intraarterial infusion. The obstructions were 2–12 months old and from 7 to 18 cm in length. Urokinase was infused at 50,000 U/h; heparin was simultaneously administered by intravenous route in doses of 800 U/h. The average duration of treatment was 18 h. Effective clot lysis was accomplished in 18 cases (85%); 15 patients had underlying stenoses treated by balloon dilatation to prevent rethrombosis. Of the primarily recanalized arteries, two reoccluted within 4 weeks.     

尿激酶动静脉溶栓治疗犬急性肺动脉栓塞的对照研究

目的 评价动脉内尿激酶(UK)溶栓治疗犬急性肺动脉栓塞的安全性和有效性.方法 用犬自体血栓建立选择性急性肺动脉栓塞模型,24只犬随机分为动脉溶栓组(30 min内经导管注入UK10 000 u/kg)、静脉溶栓组(2 h内经静脉滴入UK 20 000 u/kg)及对照组(2 h内经静脉滴入生理盐水100ml),每组8只.监测其平均肺动脉压(PAMP)、血气分析(PaO2、PaCO2)、凝血指标(PT、APTT)和D-二聚体(D-D)以及肺动脉造影复查.结果 溶栓后2 h三组PAMP、PaO2及D-D值比较差异有统计学意义(P＜0.05),溶栓后4 h动脉组与静脉组的PAMP、PaO2及D-D值比较无差异(P＞0.05).造影复查显示:动脉组比静脉组能更快溶解血栓,恢复肺组织血供.结论 动脉溶栓较静脉溶栓所需的UK剂量小,并能更快降低肺动脉压、提高动脉血氧分压,恢复肺组织血流.     

Local thrombolysis in femoropopliteal occlusion: Early and late results

The early and late results of local thrombolysis with low-dose streptokinase followed by balloon dialatation in 64 patients with an occluded femoropopliteal artery are reviewed. The primary success rate was 77% for the native arteries; it was higher (80%) for short (<10 cm) as compared with long occlusion (40%) and for patients with claudication as compared with those with advanced ischemia (89% versus 48%). Eleven complications were observed in 10 patients, most frequently a local hematoma at the puncture site. Ascending thrombosis and absence of lysis or incomplete lysis were the main reasons for failure. The cumulative patency rate after 1 and 2 years follow-up was 87% and 82%, respectively.     

Recanalization of Acute and Subacute Femoropopliteal Artery Occlusions with the Rotarex Catheter: One Year Follow-up, Single Center Experience

Purpose: To assess the efficacy and safety of a new rotational catheter for percutaneous removal of fresh and organized thrombi in the femoropopliteal artery. Methods: Forty-one limbs in 38 patients (age 56–90 years, mean 75.6 years) with acute, subacute or chronic femoropopliteal occlusions of 1–180 days’ duration (mean 31.6 days) were treated with the Rotarex device. The Fontaine stage was mainly IIB (Rutherford 2–3, 22 patients) or III (Rutherford 4, 14 patients). The length of occlusion varied from 2 to 35 cm (mean 13.1 cm). After recanalization percutaneous transluminal angioplasty (PTA) was performed if there was a residual stenosis of >25%. Patients were followed up with color Doppler ultrasound at 48 hr and clinically with Doppler pressures and oscillometry at 3, 6, and 12 months. Results: After an average of two passages with the Rotarex catheter all but two limbs required PTA for residual stenosis >25%. Five patients needed additional stenting. Major complications were one groin hematoma requiring blood transfusion and one arteriovenous fistula spontaneously thrombosing after unsuccessful primary prolonged balloon dilation. Distal embolizations occurred in 10 patients; 6 clinically relevant emboli were aspirated. All occlusions were technically successfully recanalised there were 2 early reocclusions after 1 day and two at 2 weeks. Brachial–ankle indices improved from an average of 0.41 before to 0.93 after recanalization. Primary and secondary patency rates were 62% / 84% after 6 months and 39% / 68% after 1 year. The amputation-free survival at 12 months was 100%. Conclusion: The Rotarex mechanical thrombectomy device is an efficient, quick, easy to handle, and safe tool for the treatment of acute, subacute or even chronic peripheral arterial thromboembolic occlusions. It can be used for short or long occlusions with equal success, provided the obstruction is not heavily calcified and has been safely passed with a guidewire first.     

低剂量尿激酶较长时间经导管直接溶栓术治疗急性髂-股静脉血栓形成的安全性和临床疗效

目的 探讨低剂量尿激酶较长时间经导管直接溶栓术(CDT)治疗急性髂-股静脉血栓形成的安全性及临床疗效.方法 搜集2005年1月至2011年3月间,采用CDT治疗且至少有12个月临床随访资料的,单侧急性髂-股静脉血栓形成的63例患者的临床资料.对CDT期间患者出现的并发症、血栓清除率、置管灌注持续溶栓时间、尿激酶用量、患肢消肿程度以及临床随访资料进行回顾性分析.计数资料用Fisher精确概率法检验.计量资料多组间比较采用方差分析,两两比较用LSD检验.对不同时间点的血栓清除率比较用重复测量资料的方差分析.结果 CDT期间没有肺栓塞和大出血发生,小的出血并发症10例(15.9％),其中沿血管鞘边缘渗血3例、穿刺点周围皮下瘀斑或血肿3例、血尿3例、牙龈出血1例.因置管引起并发症4例(6.3％),其中穿刺点周围软组织炎症表现3例、血管鞘周围继发血栓1例.53例(84.1％)患者CDT第4～8天血栓溶解程度达到Ⅲ级和Ⅱ级.CDT中,尿激酶50万U/d和75 U/d灌注溶栓获得的血栓清除率分别为(91.2±10.1)％和(91.3±12.2)％,明显优于25万U/d的(75.9 ±20.1)％(P＜0.05),但尿激酶50万U/d和75万U/d二者间的血栓清除率差异无统计学意义(P＞0.05);尿激酶50万U/d和75万U/d灌注溶栓达到Ⅲ级时的平均置管时间[分别为(7.1±0.9)d和(6.2±1.3)d]与Ⅱ级时的平均置管时间[分别为(6.4±1.0)d和(6.0±0.8)d],差异均无统计学意义(P＞0.05).随置管灌注时间的延长,平均血栓清除率有增加的趋势(P＜0.05).CDT 24 h后58例(92.1％)患肢软组织张力减轻,48 h后患肢周径[大腿中部为(54.25±5.79) cm,小腿中部为(44.05 ±5.18)cm]缩小,同术前[大腿中部为(56.46±5.91)cm,小腿中部为(45.68 ±5.16)cm]比较差异有统计学意义(P＜0.05),出院时患肢周径[大腿中部为(49.00±4.67)cm,小腿中部为(38.41±4.15)cm]同健侧[大腿中部为(48.38±4.68)cm,小腿中部为(37.73±3.92) cm]比较差异无统计学意义(P＞0.05).术后6个月时髂静脉支架通畅率91.1％(41/45).12个月时多普勒超声显示11例开通的股静脉瓣膜功能有反流征象.结论 采用低剂量尿激酶、较长时间经导管直接溶栓术治疗急性髂-股静脉血栓形成具有较高的安全性和满意的临床治疗效果.     

Percutaneous implantation of a catheter with subcutaneous reservoir for intraarterial regional chemotherapy: Technique and preliminary results

Purpose: We present the technique and the preliminary results of percutaneous implantation of intraarterial catheters connected to a subcutaneous infusion reservoir for prolonged regional chemotherapy of hepatic and extrahepatic tumors. Methods: Two hundred patients with primary or secondary hepatic neoplasms, pelvic, pancreatic, renal, lingual, and breast cancer underwent the procedure. The access was the left axillary artery (188 patients) and the femoral artery (12 patients). The catheter tip was placed in the hepatic (170 patients), hypogastric (18), splenic (4), internal thoracic (2), gastroduodenal (3), renal (2) or the external carotid artery (1). The catheter was connected to a subcutaneous reservoir and filled with heparin; chemotherapeutic infusion was subsequently started. Results: One hundred percent immediate technical success was obtained. Forty-three of 200 (21.5%) patients had a complication: 29 patients had a catheter dislodgment, nine had arterial thrombosis, three had a pseudoaneurysm of the left axillary artery and two had a port pocket hematoma. Most complications (37/43, 86%) were treated percutaneously without interruption of chemotherapy. In only six cases (3% of the total population) was chemotherapy discontinued due to the complication itself. The mean duration of catheter patency was 7.2 months. Conclusion: Percutaneous placement of an intraarterial catheter is feasible and causes less discomfort to the patient than the surgical approach. The technique has an acceptable complication rate (21.5%), similar to that for surgical implantation (17.8%), with the advantage that in most cases the complications can be resolved percutaneously. This technique represents an alternative to surgical implantation in the treatment of liver metastases from colorectal cancer and opens new therapeutic possibilities for the local prolonged treatment of other kinds of tumor, though its clinical efficacy must be assessed in selected trials.     

Budd-Chiari综合征:下腔静脉阻塞合并血栓的可回收内支架设计与应用

目的设计可回收内支架以治疗下腔静脉阻塞并血栓型Budd-Chiari综合征(BCS)并观察其临床效果。方法根据下腔静脉合并血栓型BCS病变特点,设计可回收内支架。4例下腔静脉阻塞并血栓型BCS,行钝性破膜小球囊预扩张后置入可回收内支架压迫血栓,再使用大球囊充分扩张闭塞段,完全开通闭塞的下腔静脉。术后给予抗凝溶栓治疗,待血栓消失后经颈内静脉或股静脉将可回收内支架取出。其中下腔静脉节段性闭塞合并血栓者同时在原闭塞段置入“Z”型支架,术后彩超随访。结果4例患者成功介入治疗,血栓短期内消失,可回收内支架顺利取出,术中术后未发生肺动脉栓塞、下腔静脉破裂以及其他并发症。彩超随访3个月,可回收内支架置入部位未见血栓形成、管壁增厚和局部再狭窄。结论应用可回收内支架治疗BCS下腔静脉病变合并血栓安全、有效,对局部血管壁无不良影响,可替代永久内支架置入,值得推广。     

A Newly Designed Nitinol Stent: Early Clinical Experience in the Treatment of Iliac Artery Stenoses and Occlusions

Objective

To investigate the effectiveness of the newly designed Niti-S stent in the management of iliac arterial stenoses and occlusions.

Materials and Methods

Stenoses (n=25) or occlusions (n=5) in the iliac arteries of 25 patients (30 limbs) were treated. The site of the lesions was the common (n=15) or external (n=11) iliac artery, or both (n=4). Eight limbs were treated for diffuse disease, six for highly eccentric lesion, five for occlusive lesion, and 11 for failed angioplasty.

Results

In all patients, technical success was achieved without major complications. One death, not procedure-related, occurred within 30 days. Ankle-brachial indexes improved from 0.63±0.30 to 0.99±0.21, and ischemic symptoms showed improvement in 22 patients (88%). Fontaine classifications before stenting, namely IIa(n=3), IIb(n=16), III(n=2), and IV(n=4) improved to I(n=17), IIa(n=5), and IV(n=3). Follow-up over a 27 (mean, 19.8±8)-month period showed that cumulative patency rates were 95.8% at 1 year and 86.2% at 2 and 3 years. No significant decrease in the mean ankle-brachial index was observed.

Conclusion

The Niti-S stent appears to be a safe and effective device for the treatment of iliac stenoses and occlusions. These preliminary results require confirmation with a larger series.     

手动移床磁共振下肢动脉3D CE MRA技术及临床应用

目的：探讨手动移床磁共振下肢血管成像技术及其临床应用价值。方法：应用3D小角度激发快速梯度回波序列（3D FLASH）,对23例疑有下肢血管病变的患者,行磁共振下肢血管成像。使用Siemens Symphony 1.5T超导型磁共振扫描仪,使用头线圈及体表面线圈进行扫描,手动移床三段采集双下肢动脉血管图像,重组方法为MIP及MPR。结果：23例患者均获成功,其中16例经DSA证实,3D CE MRA图像直观、完整地显示腹、盆腔和下肢动脉结构和血管病变部位及范围。结论：手动移床磁共振下肢血管成像能较好的显示下肢动脉病变的范围和程度,快速、安全、有效,有利于血管疾病的检出,可以为临床提供更丰富的信息。     

Catheter lysis and percutaneous transluminal angioplasty below the knee via the popliteal artery in a patient with femoral artery obstruction: Technical note

Acutely occluded lower leg arteries in a patient with a chronically obstructed superficial femoral artery were successfully treated by catheter lysis and dilatation via the popliteal artery.     

^99mTc—SZ—51在下肢血栓放射免疫显像中的初步应用

为评估放射免疫显像（ＲＩ）对下肢血栓的诊断价值，应用亚锡离子还原法进行９９ｍＴｃ标记抗人活化血小板单克隆抗体ＳＺ５１，对８例下肢血管性病变患者，静脉注射９９ｍＴｃＳＺ５１后２、４和６小时行平面显像，必要时加做断层显像，或采集２４小时后的延迟图像。结果：８例中７例属下肢血管血栓，１例为下肢静脉曲张伴皮肤溃疡。７例中３例新鲜血栓ＲＩＩ均为阳性，其中１例经溶栓治疗，ＲＩＩ复查转为阴性；另外４例系陈旧性血栓，ＲＩ阴性。结论：９９ｍＴｃＳＺ５１ＲＩＩ适用于下肢新鲜血栓的诊断，尚可有效地观察溶栓疗法的效果。     

Unruptured Aneurysms with Cranial Nerve Symptoms: Efficacy of Endosaccular Guglielmi Detachable Coil Treatment

Objective

To evaluate the efficacy of endosaccular Guglielmi detachable coil (GDC) treatment of unruptured aneurysms causing cranial nerve (CN) symptoms.

Materials and Methods

Among a database of 218 patients whose aneurysms were treated using GDC, seven patients met the criteria for unruptured aneurysms presenting with symptoms and signs of CN palsy. Changes in CN symptoms before and after GDC treatment were reviewed.

Results

Aneurysms were located in the internal carotid-posterior communicating artery (n=3), the basilar bifurcation (n=1) and the cavernous internal carotid artery (n=3). CN symptoms included ptosis (n=6), mydriasis (n=2), and extraocular muscle (EOM) disorder (CN III: n=4; CN VI: n=3). Overall, improvement or resolution of CN symptoms after treatment was noted in five patients. CN symptoms in cases involving small (≤ 10 mm) and intradural aneurysms tended to respond better to GDC treatment. Ptosis was the initial symptom to show improvement, while EOM dysfunction responded least favourably.

Conclusion

GDC coil packing appears to be an appropriate treatment method for the relief of CN symptoms associated with intracranial aneurysms.     

下肢深静脉血栓介入治疗发生肝素诱发血小板减少伴血栓形成综合征一例

临床资料患者女,70岁。因右下肢胀痛1周,渐进性加重活动受限3 d入院。查体:右侧下肢肿胀明显,肌张力较对侧高,皮色加深,右侧深静脉走形区压痛。彩色多普勒超声检查示:右侧下肢深静脉血栓形成(DVT)急性期。治疗方案:①右髂股静脉导管溶栓;②下腔静脉内置入可回收滤器预防肺动     

Comparative study of predilation with stent filter for Budd-Chiari syndrome with old IVC thrombosis: a nonrandomized prospective trial

Purpose

To evaluate whether predilation approach yield intermediate-term results were better than those with stent filter approach.

Materials and methods

59 BCS patients with old IVC thrombosis were selected for the treatment with a stent filter (n = 33, group A) or predilation (n = 26, group B) before thrombolysis, and subsequently underwent color Doppler ultrasound follow-up at our hospital. Data relating to the technical success, color Doppler ultrasound results, cost, mortality, morbidity, and final clinical results were collected prospectively and follow-ups were performed 1, 3, 6, and 12 months after the procedures, and annually thereafter.

Results

Sent filter placement, thrombolysis and predilation were technically successful in all patients, with no procedure-related complications. Stent migration upward occurred in two patients, and removal of the stent filter was technically successful in 32 of 33 patients in group A. Inferior vena cavagrams performed before dilation with a 30-mm balloon catheter demonstrated that the IVC thrombus had completely resolved in all patients without pulmonary embolism. Reobstruction of the IVC without thrombosis was observed in three patients. Short of higher overall complications and costs in group A when compared to group B, there were no other differences in the clinical and color Doppler ultrasound findings, and primary patency rate between the two groups. All patients are alive with no recurrence of thrombosis at the time of this report.

Conclusions

BCS patients with old IVC thrombosis treatment with predilation approach yielded intermediate-term results that were better than those with the stent filter approach.     

Postcatheterization Femoral Arteriovenous Fistula: Endovascular Treatment with N-Butyl-Cyanoacrylate Embolization

We report a case of an iatrogenic femoral arteriovenous fistula (AVF) in a 67-year-old man presenting with right femoral bruit on the day after sheath removal for cardiac catheterization. This was successfully treated with embolization using N-butyl-cynoacrylate (NBCA) through a coaxial microcatheter. Transcatheter embolization of iatrogenic femoral AVFs with NBCA in selected cases may be a safe and effective treatment in the presence of long fistula tracts. It is then easy to perform in experienced hands and relatively inexpensive.     

Computed tomographic diagnosis of superior mesenteric artery embolic thrombosis associated with renal and splenic infarction

We describe a case of apparent embolic thrombosis of the superior mesenteric artery that on computed tomography (CT) was noted unexpectedly, making the diagnosis of ischemic bowel disease straightforward. It occurred together with the typical CT findings of renal and splenic infarction. This diagnosis was verified by angiography that provided more information and was confirmed at surgery.     

Iliocaval stenosis and iliac venous thrombosis in retroperitoneal fibrosis: Percutaneous treatment by use of hydrodynamic thrombectomy and stenting

A case of bilateral iliac stenosis and caval stenosis due to retroperitoneal fibrosis was treated by caval stenting and iliac balloon angioplasty, but was complicated by subsequent iliac thrombosis. Venous thrombectomy was successfully achieved by hydrodynamic thrombectomy, and iliac patency was stabilized by bilateral stent insertion.     

Postpartum ovarian vein thrombosis with simultaneous pyelocaliectasis: diagnosis and follow-up by MR imaging. Case report and literature review

We describe the critical role of MR imaging in a case of postpartum ovarian vein thrombosis (OVT) with concomitant pyelocaliceal ectasia. MR imaging confirmed the diagnosis suspected on the basis of ultrasonography and computed tomography by demonstration of a subacute clot with high signal intensity within the right ovarian vein and its complete resolution after anticoagulant therapy. MR imaging is a useful noninvasive, accurate tool for the diagnosis and follow-up of this potentially life-threatening condition, providing information helpful for choosing a prompt medical treatment rather than a surgical therapy. To our knowledge, no previous case of OVT causing pyelocaliceal ectasia documented by MR imaging has been reported. However, even though our case is suggestive, a cause–effect relationship between OVT and hydronephrosis could not be demonstrated with certainty. Electronic Publication     

Popliteal artery thrombosis in a patient with Cogan syndrome: Treatment with thrombolysis and percutaneous transluminal angioplasty

A 31-year-old woman with Cogan syndrome (a rare form of systemic vasculitis) was evaluated for a cold, painful left foot with diminished pulses. Arteriography demonstrated thrombosis of the left popliteal artery with evidence of vasculitis. Thrombolytic therapy was begun with initial success but eventual rethrombosis. After reinitiating thrombolytic therapy combined with intraarterial vasodilator therapy, successful angioplasty was performed with sustained results, at 6-month follow-up.     

Treatment of acute basilar artery thrombosis with a combination of systemic alteplase and tirofiban, a nonpeptide platelet glycoprotein IIb/IIIa inhibitor: report of four cases.

In four patients with acute basilar artery thrombosis, complete arterial recanalization and good neurologic outcome were achieved with a treatment combining alteplase with tirofiban. In no cases were cerebral or extracerebral hemorrhagic complications observed. Combined fibrinolytic agents and glycoprotein IIb/IIIa inhibitors may have high potential in the treatment of acute cerebrovascular thrombosis.