John M. Porter

Deep Vein Thrombosis Treated With Streptokinase or Heparin Follow-Up of a Randomized Study

Twenty-seven patients with deep vein thrombosis whose primary therapy was randomized between streptokinase and heparin were reevaluated clinically and by ascending venography after a mean period of 7 months. Normal venograms were found in 6 (40%) of the streptokinase-treated patients and in 1 patient (8%) who had heparin therapy. Segmental valve preservation was found in 1 patient from each group. All patients with complete or partial valve preservation became asymptomatic. Vein re canalization without preservation of valves occurred in 18 patients: 8 (54%) of those on streptokinase, and 10 (83%) of those on heparin. At the time of follow-up, 11 of these 18 patients, including 8 who had had prior thrombosis, reported peripheral edema; the postphlebitic syndrome devel oped in 1. Factors favoring a good outcome of acute venous thrombosis were (1) no prior thrombotic disease, (2) localized thrombosis, and (3) prompt streptokinase therapy.

Streptokinase and Heparin in the Treatment of Pulmonary Embolism: A Randomized Comparison

Treatment with streptokinase followed by heparin was compared on a randomized basis with treatment with heparin alone in patients with acute pulmonary embolism. The diagnosis and results of treatment were established by pulmonary angiography. Fifteen patients received streptokinase and 16 received heparin alone. Complications included bleeding and pyrexia in both treatment groups and anaphylaxis in a patient receiving streptokinase. There were three deaths attributed to the disease its treatment. Patients in the strepto kinase group had significantly greater angiographic improvement (P = 0.0125) than those in the heparin group.

Fresh and cryopreserved venous allografts in genetically characterized dogs

The autogenous saphenous vein is universally accepted as the conduit of choice for arterial bypass procedures in small vessels. Unfortunately, 2030% [S] of patients do not possess an adequate saphenous vein because of previous vein stripping, thrombophlebitis, or venous anomalies. Abundant laboratory and clinical research to date has failed to produce a uniformly successful prosthetic graft for small vessel application, although modest progress has been made in recent years. Attention has inevitably turned to the possible use of venous allografts in those patients requiring small vessel bypass procedures who do not possess an adequate saphenous vein. Considerable investigative and clinical data have been accumulated on the use of venous allografts in arterial surgery since the beginning of this century. With several isolated exceptions [21, 221, the use of venous allografts in patients has been disappointing to data. Many investigatars, however, feel the venous allograft may have a role in future arterial surgery if the allograft can either be antigenically modified prior to implantation or if the immunologic reactivity of the host can be modified. A recent important paper by Weber ef al. [24] indicated a marked improvement in the function of venous allografts following cryo-

Percutaneous angiographic embolization: A procedure of increasing usefulness: Review of a decade of experience***

During the past decade percutaneous therapeutic vascular occlusion was performed on 152 occasions in 124 patients. The primary indication for vasoocclusive therapy was acute or recurrent bleeding. Upper gastrointestinal bleeding from arterial sources was controlled in 92 percent of patients and acute variceal bleeding in 83 percent. Renal embolization was performed for palliation of severe pain and hematuria from unresectable renal primary or secondary malignancies, to decrease blood loss and facilitate surgery in operable renal tumors, and for ablation of renal function to control chronic protein loss or severe hypertension. Our encouraging experience convinces us that transcatheter embolization is a useful, safe and effective procedure in selected patients. It seems certain that the technique of therapeutic embolization will be improved, its indications extended and its application become commonplace whenever angiographic skills and facilities exist.

Value of angiography in the management of abdominal aortic aneurysm

The value of angiography in the management of abdominal aortic aneurysms (AAA) was assessed in 100 consecutive patients with AAA. Angiographic information influenced management decisions and/or surgery performance in 75: In 23 patients at high risk for surgery because of associated medical problems, it helped in deferring surgery; in 52 patients it resulted in a change of operation from a standard aneurysm resection with conventional grafting to a more conservative procedure (three patients), more extensive grafting (45 patients) and/or the addition of other vascular reconstructions (32 patients). Angiography is considered an integral step in the routine preoperative workup of AAA and is particularly valuable for the determination of important anatomic details about the aneurysm (upper and lower extensions, relation to the renal arteries), the detection of associated vascular disease (of renal, visceral, pelvic and peripheral arteries), and the demonstration of aberrant renal arteries and collateral visceral circulation. Catheter techniques are considered most suitable and safe for examination of AAA.

Thrombolysis as an Alternative to Pulmonary Embolectomy

In the past two decades an abundance of medical literature has been published describing the incidence, diagnosis, natural history, and treatment of pulmonary embolism. From this wealth of data, diagnostic and therapeutic trends are emerging which will likely have great influence on the future management of patients with pulmonary embolism. A clinician treating patients with suspected pulmonary embolism is first confronted by the need to establish a firm diagnosis and then to choose between three primary treatment modalities anticoagulation with heparin, thrombolytic therapy with urokinase or streptokinase, or pulmonary embolectomy. This brief review attempts to describe the magnitude of the clinical problem and to provide background data on the various treatment modalities. A detailed discussion of diagnostic studies is not within the scope of this paper.

Urinary tract fibrinolysis

Abstract Tissue samples from all portions of the urinary collecting system were assayed for the presence of tissue fixed plasminogen activator activity. Daily urine samples were obtained from 17 patients following urinary tract surgery and assayed for the presence of fibrin-fibrinogen degradation products (FDP). Hematuria was present in all samples. Urine samples were obtained from 17 patients with chronic renal disease and proteinuria and similarly assayed for FDP. All portions of the urinary collecting system contained considerable tissue fixed plasminogen activator activity. All patients with hematuria had FDP present in the urine, indicating that fibrinolysis is the process by which the clots are removed from the urinary tract. These results indicate that correlation of urinary FDP with renal parenchymal disease should be attempted only in the documented absence of hematuria.

Thrombectomy and thrombolysis - therapeutic alternatives?

From the Departments of Surgery, Diagnostic Radiology, and Medicine, University of Oregon Health Sciences Center, Portland, Oregon. Supported by Grant RR-00334 from the General Clinical Research Centers Branch of the Division of Research Resources, National Institutes of Health. Two potent thrombolytic drugs streptokinase (SK) and urokinase (UK) will probably soon be available for general use in the United States. Physicians caring for patients with vascular thromboses will face potentially difficult therapeutic choices between thrombolytic therapy, anticoagulant therapy, or surgical embolectomy or thrombectomy in the management of these patients. This report reviews the use of thrombolytic therapy in the treatment of three common clinical thrombotic conditions for which surgical thrombectomy has frequently been used: venous thrombosis, pulmonary embolism, and thrombotic or embolic peripheral arterial occlusion. Tentative conclusions are offered on the selection of therapy for these three conditions. To date, both SK and UK have been extensively evaluated in the treatment of pulmonary embolism. SK has also been widely used in the treatment of peripheral venous and arterial thromboses. UK has not been used in enough patients with the latter two conditions to permit even tentative conclusions about its effectiveness, although it will probably be as effective as SK. Thrombolytic therapy has been used in a few patients with other thrombotic disorders, such as cerebral infarction,1 myocardial infarction,’ and retinal vascular disorders,3 but not enough information is available to assess the ultimate role of thrombolytic therapy in these conditions. However, results to date have failed to convincingly demonstrate therapeutic benefits. These conditions will not be considered further in this report.