Local fibrinolytic therapy with terrilytin in coagulated hemothorax and pleural empyema

On the basis of experimental and laboratory investigations high fibrinolytic effect of the home proteolytic enzyme terrilythin and the absence of general toxic reactions after intrapleural administration of the drug have been proved. The article describes results of clinical results of clinical tests of the effectiveness of terrilythin in coagulated hemothorax after traumas of the chest and operations on the lungs and in 55 patients with acute pro-fibrinous pleurisy. The successful preventive sanitation was performed in 43 of 50 patients with coagulated hemothorax and initial symptoms of the infectious process as well at the development of pleural empyema were averted.     

Local intraarterial fibrinolytic therapy for embolic stroke associated with vascular anomalies--two case reports

Two cases of embolic stroke associated with vascular anomalies were treated by intraarterial fibrinolytic therapy. A 78-year-old male had embolic stroke associated with fenestration of the middle cerebral artery (MCA). The embolus lodged in the terminal portion of the right internal carotid artery (ICA) and in the M2 portion of the right MCA. The fenestration was not detected before local fibrinolytic therapy, but was identified by postinterventional angiography. An 82-year-old female had a left-sided persistent primitive trigeminal artery (PPTA), and the embolus lodged in the terminal portion of the left ICA. Left internal carotid angiography also showed rich collateral circulation via the abundant leptomeningeal anastomosis. The PPTA involved the left ICA, so the anomalous anatomy had to be considered in performing local thrombolysis. However, the rich collateral circulation allowed recanalization of the occluded ICA without inducing bleeding. Dissolution of persistently adherent emboli must be performed with great care because of the possibility of such rare vascular anomalies.     

Normal angiograms and carotid pathology

Nonstenotic ulcerated atherosclerotic plaques of the carotid arteries may be associated with symptoms of transient ischemic attacks, amaurosis fugax, and stroke. Preoperative evaluation of patients with these symptoms has traditionally included ultrasound and arch aortography angiograms of the area of the carotid bifurcation. Recent evidence has shown that ultrasound is more accurate in detection and morphologic delineation of these nonstenotic lesions. We analyzed the hospital records of 21 patients with ultrasonographic evidence of disease in whom arteriograms were negative. The patient group comprised 15 men and six women, with an average of 66 years. All patients had symptoms of hemispheric transient ischemic attacks and were evaluated with B-mode ultrasound and arteriography. Ultrasound was positive and arteriogram "negative" in all of the patients (i.e., described by the radiologist as without hemodynamic significant disease or ulceration, or as normal). The ultrasound diagnosis was confirmed at operation with findings of 20 to 50 per cent stenosis and ulcerative plaques. At retrospective review of the arteriograms, three ulcerations were found in the 21 patients. We conclude that B-mode ultrasound better defines nonstenotic ulcerative lesions and decisions to perform carotid endarterectomy may be based on either positive test. An ulcerative plaque by B-mode ultrasound and appropriate symptoms, therefore, may not require angiography before operation.     

Surgical implications of fibrinolytic therapy

Intraarterial fibrinolytic therapy was used in 37 cases (34 patients) of severe peripheral ischemia. Nineteen patients (56 percent) required surgical intervention (5 amputations and 14 successful reconstructive procedures). Twenty-four patients (71 percent) were significantly improved (average ankle-to-arm index 0.84), whereas only 5 patients (15 percent) lost their limbs. Five patients were angiographically unchanged with no or slight improvement in the ankle-to-arm index (0.22 to 0.32) and were discharged on anticoagulant therapy. One death and two cerebrovascular accidents occurred. The usefulness of intraarterial fibrinolytic therapy needs to be evaluated within the total realm of vascular surgery. It offers options for therapy where previously none existed. Some situations might be treated equally well with either intraarterial fibrinolytic therapy or surgery. Finally, surgery might be required to maintain initial successful results with intraarterial fibrinolytic therapy or to rescue intraarterial fibrinolytic therapy failures in striving to achieve superior results in limb salvage.     

Local hemostasis during the carotid endarterectomy under condition of antithrombocytic therapy]

Comparative studying of preparation TachoComb application efficacy and the convenient tampon procedure for stopping of bleeding from the suture line, fixing the expanding flap, made of polytetrafluoroethylene, in arteriotomy zone was studied in the patients, operated for carotid arteries stenosis and obtaining Plavix preparation protractedly in 75 mg dosage. The preparation TachoComb application have had promoted the operative time reduction as well as the bleeding duration and the blood loss volume.     

Intrapericardial fibrinolytic therapy in purulent pericarditis.

OBJECTIVE: Purulent pericarditis is a rare disease that is being conventionally managed with intravenous antibiotics and pericardial drainage. In our study, we used intrapericardial fibrinolytic treatment together with pericardiocentesis and antibiotic therapy. We evaluated the role of intrapericardial fibrinolytic treatment in nine purulent pericarditis patients. METHODS: Six children and three adult patients with purulent pericarditis, aged between 5 and 50 years, were treated with intrapericardial fibrinolysis by streptokinase. Intrapericardial drainage catheter was placed into the subxyphoidal localization under local anaesthesia and echocardiography guidance, streptokinase was infused into the pericardial sac as the fibrinolytic agent. RESULTS: Repeat echocardiograms showed no reaccumulation of pericardial effusions, pericardial thickening or constrictions. No patients had systemic bleeding, arrhythmias, or hypotension. There was one death which was due to sepsis and congestive heart failure. CONCLUSION: We believe that early pericardial drainage and intrapericardial fibrinolysis appears to be safe and effective in the treatment of purulent pericarditis.     

Intraoperative fibrinolytic therapy: experimental evaluation

Percutaneous intra-arterial infusion of fibrinolytic agents has emerged as an alternative to embolectomy in selected patients with acute arterial occlusions. The combination of fibrinolytic therapy and embolectomy may be superior to either modality alone. This experiment was designed to determine safety and efficacy of intraoperative fibrinolytic therapy as an adjunct to catheter embolectomy. Forty hind limbs in 20 adult mongrel dogs were embolized with thrombus created in vitro. After 24 hours, bilateral transfemoral embolectomy was followed by intra-arterial, intraoperative infusion. Fifteen limbs (control) received 250 ml of saline solution during a 30-minute period; 25 limbs (experimental) received an arterial infusion of 60,000 units of streptokinase during a 30-minute period (SK 30'). In five limbs of each group, 500 units of heparin (H) was added. In five experimental limbs the streptokinase infusion time was increased to 60 minutes (SK 60'). Arteriograms and blood flow measurements were obtained before and after embolectomy (PE) and after infusion (PI); the results were compared. Improvement between the PE and PI angiograms was seen in 20% (3 of 15 dogs) of control subjects. In contrast, improvement after the infusion was evident in 100% (5 of 5 dogs) of dogs given SK plus H 30' (p less than 0.01), in 80% (12 of 15 dogs) of dogs given SK 30' (p less than 0.01), and in 20% (1 of 5 dogs) of dogs given SK 60'. A trend toward increased blood flow was noted in the experimental group. There were no intraoperative complications with hemostasis or postoperative bleeding (36-hour observation). We conclude that intraoperative fibrinolytic therapy in dogs is safe and effective as an adjunct to thromboembolectomy. A human clinical trial is recommended.     

Local anaesthesia for carotid endarterectomy

Carotid endarterectomy is preventative surgery aimed at reducingthe rate of stroke in patients at high risk of such an event.Approximately 1% of the British population over 75 years oldwill die as a result of carotid artery disease each year. Performing a carotid endarterectomy itself has considerablerisk. The rate of perioperative stroke has been reported as2.2% overall – 1.7% in patients with no prior historyof CVA (cardiovascular accident) and 4.2% in those with a previousstroke. Many of these patients have widespread arteriopathicand ischaemic heart disease, chronic obstructive pulmonary diseaseor diabetes. In addition, they may be smokers and elderly. Theco-morbidity associated with carotid disease is therefore considerable.The combined perioperative mortality from myocardial infarctionas well as stroke is likely to be less than 2%.     

局部miR-126基因治疗促进小鼠缺血后肢血管新生的观察

目的:通过体外构建重组腺病毒mi R-126,应用于小鼠缺血后肢腓肠肌局部治疗,观察mi R-126对缺血局部具有促血管新生作用。方法:重组腺病毒mi R-126包装、纯化、滴度的鉴定;C57小鼠随机分为A组(C57左侧缺血后肢手术组)、B组(空病毒C57左侧缺血后肢手术组)、C组(重组腺病毒mi R-126 C57左侧缺血后肢手术组)三组,制作小鼠缺血后肢模型,术后即刻将重组腺病毒mi R-126和腺病毒各50μl局部注射于小鼠缺血左后肢腓肠肌。分别于3、7、14天各组(3只)取左后肢腓肠肌做HE染色、CD31免疫组化染色、west ern bl ot检测Akt、ERK1/2、pAkt、pERK1/2蛋白水平以及实时定量PCR检测等。结果:各种检测结果显示C组较A、B两组血管内皮细胞增生明显,新生血管数目计数明显增多,mi R-126表达水平明显增高,尤其在第7天升高最为明显,以及VEGF、bFGF等介导的I P3和MAPK信号通路中ERK1、pERK1、AKT和pAKT蛋白水平表达明显增高。结论:mi R-126局部应用于缺血后肢,通过激活Akt、ERK1/2的相关通路,促进血管新生,利于缺血后肢功能恢复。     

Local neurological complication during carotid endarterectomy

In a prospective study of 52 carotid endarterectomies there were 13 temporary cranial nerve injuries in 12 patients (25%); 7 hypoglossal nerve injuries (13.5%), 3 were asymptomatic (5.8%), 2 had mild speech difficulty (3.8%) and 2 had severe difficulty with deglutition and articulation (3.8%). A full recovery was made within 3 months in all 7 patients. Although 10 patients (19.2%) developed a hoarse voice, indirect laryngoscopy only indicated damage to the ipsilateral recurrent laryngeal nerve in 3 patients (5.8%). Both the voice and vocal cord movement returned to normal within 6 months in 2 patients and a 9 months in the third. The marginal mandibular branch of the facial nerve was injured in 3 patients (5.8%) and all recovered completely within 3 months. Following injury to the great auricular and the transverse cervical nerves injury, 13 patients (25%) had persistent irritation and paraesthesia during shaving and in cold weather lasting up to 18 months after operation. Carotid endarterectomy is associated with a much higher incidence of local nerve injury than retrospective surveys would indicate.     

Experience with fibrinolytic therapy of vascular occlusive disease

1. There may well be a place for streptokinase therapy in selected patients with chronic arterial occlusion, but the emphasis should be on developing information on selection criteria. 2. Efficacy and safety have been established for the use of streptokinase in occluded AV cannulae, but this may be more of historical than contemporary importance. 3. Although more investigation is required to define the role of lytic therapy in retinal vascular occlusion and in the hemolytic uremic syndrome, the preliminary results are encouraging and merit further attention.