Christoph Thalhammer

Effect of prolonged treatment with compression stockings to prevent post-thrombotic sequelae : A randomized controlled trial

OBJECTIVE Compression stockings are widely applied after acute proximal deep vein thrombosis, but their efficacy in preventing the post-thrombotic syndrome remains controversial. This study assessed the effect of prolonged compression therapy after a standard treatment of 6 months after acute deep vein thrombosis. METHODS Of 900 patients screened, we randomly allocated 169 patients with a first or recurrent proximal deep vein thrombosis after receiving 6 months of standard treatment to wear compression stockings or not. Primary efficacy analysis was performed on the end point of emerging skin changes (C4-C6 according to the CEAP classification). Secondary analysis was done on symptoms associated with post-thrombotic syndrome. All analyses were done according to the intention-to-treat principle. RESULTS The primary end point occurred in 11 patients (13.1%) in the treatment group compared with 17 (20.0%) in the control group (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.28-1.28; P = .19). Mean follow-up was 3.2 years and 2.9 years, respectively. Five additional patients in the control group required compression therapy owing to post-thrombotic signs and symptoms not included in the primary end point. No venous ulceration was observed in either group. Within subgroup analyses of the primary end point, we observed a large sex-specific difference between women (HR, 0.11; 95% CI, 0.02-0.91) and men (HR, 1.07; 95% CI, 0.42-2.73). Symptom relief was significant in favor of compression treatment during the first year but not thereafter. CONCLUSION Prolonged compression therapy after proximal deep vein thrombosis significantly reduces symptoms and may prevent post-thrombotic skin changes. Whether these findings translate to the prevention of advanced disease states with ulcerations remains unclear.

Percutaneous treatment of pseudoaneurysms and arteriovenous fistulas after invasive vascular procedures.

Development of femoral artery pseudoaneurysms and arteriovenous fistulas represents a continuing problem after vascular diagnostic and interventional procedures. For most patients, ultrasound‐guided compression is an effective method of treating such complications. However, in patients requiring a continuous anticoagulant regimen, in those with large arteriovenous fistulas or in patients suffering from painful groin hematomas, compression repair is less successful. We therefore assessed the feasibility, efficacy, and long‐term results of interventional percutaneous treatment of these complications. In a 40‐month period, we treated 53 consecutive patients with 30 pseudoaneurysms, 21 arteriovenous fistulas, and 2 combined lesions. The intervention was successful in 47 patients: 32 lesions were treated by implantation of covered stents, 14 by embolization techniques, and 1 by a combined procedure, surgical repair being necessary only in 6 patients. After a clinical and ultrasonic follow‐up of 301 ± 280 days, we noticed four late stent occlusions, especially in patients with poor peripheral runoff. Lesions with a distinct connection channel to the vessel lumen should be treated by coil embolization. In lesions originating from the femoral bifurcation with a broad base, surgical repair is necessary. Stenting of the superficial femoral artery with poor runoff should be avoided. Our results suggests that percutaneous closure of false aneurysms and arteriovenous fistulas after invasive procedures with unsuccessful ultrasonic compression repair is an attractive alternative to surgical treatment. Cathet. Cardiovasc. Intervent. 47:157–164, 1999.

Vascular involvement in patients with giant cell arteritis determined by duplex sonography of 2x11 arterial regions.

Objective To define the specificity and extent of duplex sonography (DS) findings suggestive of vessel wall inflammation in patients with giant cell arteritis (GCA). Methods Patients admitted between December 2006 and April 2009 to the University Hospital Basel with a suspicion of GCA were eligible for the study. DS of 2×11 arterial regions was performed in all study participants, and American College of Rheumatology criteria were applied to classify patients into GCA or non-GCA groups. Results GCA was diagnosed in 38 of the 72 participants (53%). A DS pattern suggestive of vessel wall inflammation was not observed in any of the patients in the non-GCA group but, in 21 of the 38 patients with GCA (55%), DS signs suggestive of vessel wall inflammation of ≥1 vessel region were detected. In 12 of the 38 patients with GCA (32%), DS signs of large vessel vasculitis (LVV) were found in ≥1 vessel region(s) of both upper and lower limb vessels. Follow-up DS was performed 6 months after the baseline examination in 9 of the 12 patients with LVV and showed the persistence of most findings despite normalised signs of systemic inflammation. Conclusion DS detects changes in the vessel wall that appear to be specific for GCA; they can be present in upper and lower limb arteries of patients with GCA. Surprisingly, DS-detectable LVV and signs of systemic inflammation are largely dissociated.

Rapid improvement of nailfold capillaroscopy after intense immunosuppression for systemic sclerosis and mixed connective tissue disease

Systemic sclerosis (SSc) and mixed connective tissue disease (MCTD) are both associated with microvascular pathology. The most striking early clinical manifestation is Raynaud phenomenon (RP), which is only partly caused by functional narrowing of small vessels. Moreover, alteration of endothelial function1 and impairment of endothelial progenitor cell function in these patients have been previously described.2 This may have an important impact on capillary pathology. The resulting morphological changes can be observed by nailfold capillaroscopy (NFC). Haemorrhages, giant capillaries and avascular regions are typical findings that cannot only be detected by NFC, but also, at least in part, with moderate to substantial reliability using simpler methods such as ophthalmoscopes or dermatoscopes.3 These findings …

Associated vascular lesions in patients with spontaneous coronary artery dissection

AIM To identify vascular abnormalities in patients presenting with spontaneous coronary artery dissection (SCAD). METHODS We performed a whole-body MR angiography and a duplex sonography of the renal and carotid arteries in 12 patients (9 women, 3 men) with SCAD to identify vascular abnormalities. RESULTS MR angiography revealed abnormalities of the renal arteries in 3/12 patients (25%). All 3 patients were women, 2 presented with changes suggesting fibromuscular dysplasia (FMD), 1 had a spontaneous renal artery dissection. No other vascular abnormalities were identified in any of the patients. Duplex sonography confirmed MR findings and showed non-significant renal artery stenoses in both patients with FMD. CONCLUSIONS Abnormalities of the renal arteries were found in 3/12 (25%) of the patients with SCAD. No other vascular abnormalities were identified. Additional diagnostic tests of the renal arteries such as renal artery angiography or duplex sonography may be considered in patients presenting with SCAD.

Endothelial Cell Dysfunction and Arterial Wall Hypertrophy Are Associated With Disturbed Carbohydrate Metabolism in Patients at Risk for Cardiovascular Disease

To investigate the effects of fasting and postprandial glucose on endothelial cell function and intima-media thickness, we studied 60 men with cardiovascular risk factors. Postischemic, endothelium-dependent vasodilatation was measured after 3 minutes of ischemia at the radial artery with high-resolution echo tracking. Common carotid artery intima-media thickness was measured by B-mode ultrasound. Glucose tolerance was determined by a 75-g oral glucose load. Fasting glucose levels were inversely correlated with postischemic, endothelium-dependent vasodilatation (r=-0.24, P<0.05) and directly correlated with intima-media thickness (r=0.26, P<0.05). However, postischemic, endothelium-dependent vasodilatation and intima-media thickness were not correlated. All subjects with normal postischemic, endothelium-dependent vasodilatation also had a normal intima-media thickness, whereas some subjects with impaired postischemic, endothelium-dependent vasodilatation also had a normal intima-media thickness. Multiple regression analysis revealed a profound influence of age on intima-media thickness to the exclusion of all other variables. The same age-adjusted analysis for postischemic, endothelium-dependent vasodilatation accepted fasting glucose, followed by 2-hour postprandial glucose, as variables, but no others. Subjects with fasting glucose values >100 mg/dL showed reduced postischemic, endothelium-dependent vasodilatation (59 versus 120 microm, P<0.05) and a higher intima-media thickness (right: 0.76 versus 0.62 mm, P<0.05; left: 0.78 versus 0.63 mm, P<0. 05) compared with those with fasting glucose values <100 mg/dL. Subjects with 2-hour postprandial glucose values >125 mg/dL had no reduced postischemic, endothelium-dependent vasodilatation compared with subjects with a 2-hour postprandial glucose <125 mg/dL; however, their intima-media thickness (right: 0.66 versus 0.62 mm; left: 0. 68 versus 0.62 mm; P<0.05 for both) was greater. Thus, high fasting rather than postprandial glucose values are associated with both postischemic, endothelium-dependent vasodilatation and increased intima-media thickness. Postischemic endothelium-dependent vasodilatation may precede increased intima-media thickness.

Endovascular treatment of Angio‐Seal™‐related limb ischemia—Primary results and long‐term follow‐up

Objectives: To investigate primary success rates and long term follow‐up of endovascular treatment of AngioSeal™‐related limb ischemia. Background: Current knowledge on optimal therapy of ischemic complications following application of AngioSeal™ is limited. Methods: A single‐center prospectively maintained database was retrospectively interrogated and AngioSeal™—related complications requiring endovascular treatment over an 8‐year‐time period was identified. Results: Fifteen patients fulfilling the inclusion criteria were identified, resulting in an approximated incidence of 0.26% of all devices implanted at our institution. In all cases, the complication was managed successfully in the absence of complications. Eleven patients were treated with balloon angioplasty (PTA) and four with stent implantation because of suboptimal PTA results. Twelve patients were available for noninvasive vascular follow‐up examination for a median time of 40 months postinterventionally. Only two patients needed a second intervention consisting of balloon angioplasty due to symptomatic restenosis. At final follow‐up all patients were asymptomatic with no relevant restenosis. Conclusion: Endovascular treatment for AngioSeal™‐related limb ischemia with or without stent implantation results in an excellent immediate and long‐term clinical and hemodynamic outcome.

Markers of arterial stiffness in peripheral arterial disease

Increased arterial stiffness results from reduced elasticity of the arterial wall and is an independent predictor for cardiovascular risk. The gold standard for assessment of arterial stiffness is the carotid-femoral pulse wave velocity. Other parameters such as central aortic pulse pressure and aortic augmentation index are indirect, surrogate markers of arterial stiffness, but provide additional information on the characteristics of wave reflection. Peripheral arterial disease (PAD) is characterised by its association with systolic hypertension, increased arterial stiffness, disturbed wave reflexion and prognosis depending on ankle-brachial pressure index. This review summarises the physiology of pulse wave propagation and reflection and its changes due to aging and atherosclerosis. We discuss different non-invasive assessment techniques and highlight the importance of the understanding of arterial pulse wave analysis for each vascular specialist and primary care physician alike in the context of PAD.

Cutaneous migration of the StarClose device.

We report the first case of a transcutaneous migration of a vascular clip closure device 10 weeks after placement during femoral artery puncture for percutaneous transluminal angioplasty. We postulate focal inflammatory vascular wall changes as the predisposing factor in this patient with giant cell arteritis.

Vascular accesses for hemodialysis - an update

During the last two decades the prevalence of patients needing chronic renal replacement therapy has increased progressively. Furthermore, the dialysis population has significantly changed. Patients are older, have multiple comorbidities, and have a particularly high cardio-vascular risk. Therefore, the prerequisites for the formation of fistulae have become worse. Many centres (including our own) have formed interdisciplinary vascular access teams to provide an optimal service for these patients. Herein, we review recent studies regarding the diagnostic and therapeutic approaches for access failure. As many clinical decisions remain opinion -based we also include our personal approach resulting from regular interdisciplinary board meetings.