William F. Ruschhaupt

Thrombolysis of peripheral arterial bypass grafts: Surgical thrombectomy compared with thrombolysis ☆ ☆☆: A preliminary report

Twenty-two patients were selected from a group of 33 patients who underwent recombinant human tissue-type plasminogen activator (rt-PA) thrombolysis for thrombosed infrainguinal bypass grafts of the lower extremity and were compared with 38 matched patients who had undergone surgical thrombectomy during the same period. The proportion of persons with diabetes mellitus, smokers, and types of bypass grafts was similar in both groups. More patients in the rt-PA-treated group had hypertension (p = 0.01). To evaluate the different lengths of follow-up, Kaplan-Meier survival analysis was used with a log-rank test to compare the proportion of persons with patent grafts in the two treatment groups. At 30 days, 86% of the rt-PA-treated grafts were still patent compared with 42% of the surgically treated grafts (p = 0.001). When risk factors on the Kaplan-Meier curves were compared, there was no statistical difference with regard to graft patency among the groups. According to simultaneous Cox regression analysis, no risk factor was significantly associated with graft patency. When amputation was evaluated between treatment groups simultaneously with other risk factors in a logistic regression analysis, smoking and age of the graft were marginally significant (p = 0.07), whereas all other factors were clearly not significant. In 91% of the rt-PA-treated patients, a secondary surgical procedure was required to maintain patency of the graft segment. Eighty-nine percent of the surgically treated patients required similar graft revisions. Two patients in the surgical group and one patient in the rt-PA-treated group had major complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Ischemic rnonornelic neuropathy

Ischemic monomelic neuropathy (IMN) is an infrequently recognized type of ischemic neuropathy produced by the shunting of blood away from, or the acute noncompressive occlusion of, a major proximal limb artery. IMN consists of multiple axonal-loss mononeuropathies that develop acutely and simultaneously in the distal portion of a limb. We found stereotyped clinical and EMG features in 14 patients. In six the IMN was thromboembolic in nature, whereas in eight it was due to various vascular surgical procedures. Our experience with IMN suggests that distal axonal infarction can occur without significant muscle necrosis, supporting the hypothesis that in humans the distal nerve fibers are more vulnerable than muscle to acute noncompressive limb ischemia.

Local thrombolysis in the treatment of thrombosed arteries, bypass grafts, and arteriovenous fistulas

We reviewed the results, systemic effects, and complications associated with the selective infusion of low-dose streptokinase in 151 patients. Successful thrombus lysis was achieved in 78% of atherosclerotic thrombotic occlusions less than 30 days old, in 81% of post-procedural occlusions less than 14 days old, and in 87% of patients with thrombosed arteriovenous fistulas no more than 4 days old. During the first 12 hours of treatment 81% to 84% of patients had greater than 50% decrease in plasma fibrinogen levels and 100% showed the same decline after 24 hours of treatment. The thrombin time was prolonged to at least 1 1/2 times the control thrombin time in 33% to 42% of patients measured at 4 hours of therapy and in 93% to 97% of patients measured at 24 hours of treatment. Fifteen patients (9.9%) had major complications. Eleven of these had hemorrhagic complications, two had significant distal emboli, one had a thrombosed brachial artery, and one had a false aneurysm at the catheter entry site. We have found that selective low-dose streptokinase is effective in the treatment of acute and chronic thrombotic occlusions and is a useful adjuvant to vascular reconstruction or percutaneous transluminal angioplasty. Although the local infusion dose is substantially lower than the usual systemic dose, a systemic lytic effect was seen in all patients. Hemorrhagic complications occurred despite customary precautions.

Coronary artery disease in patients with aortic aneurysm: a classification of 302 coronary angiograms and results of surgical management

In an attempt to reduce early and late mortality caused by myocardial infarction in patients with aortic aneurysms, coronary arteriography and, when indicated, myocardial revascularization were performed prior to elective aortic reconstruction in 302 patients with infrarenal (289) or thoracoabdominal (13) aortic aneurysms. Severe correctable coronary artery disease (CAD) was identified in 31% of the entire series, whereas severe inoperable CAD was seen in another 5%. Severe, correctable CAD was documented in 42% of patients suspected to have CAD by standard clinical criteria and in 19% of those in whom CAD was not suspected. The overall mortality for 89 cardiac and 227 infrarenal aortic surgical procedures was 4,4%. Fatal complications after infrarenal aneurysm resection occurred in only one (1.6%) of 61 patients who had had preliminary myocardial revascularization.

Peripheral artery and bypass graft thrombolysis with recombinant human tissue-type plasminogen activator

Recombinant tissue-type plasminogen activator (t-PA) is a DNA-synthesized thrombolytic agent recently approved for clinical trials. We present the results of t-PA infusions in 18 patients with thrombosed peripheral arteries (12 patients) and peripheral bypass grafts (six patients). The duration of occlusion ranged from 1 to 21 days (mean, 6.8 days). Infusions of t-PA were done by way of an intra-arterial approach at a dose of 0.1 mg/kg/hr. All patients demonstrated thrombus lysis angiographically. Fifteen of 18 (83%) had clinical as well as angiographic improvement. Secondary procedures to maintain patency of the arterial segment were required in seven patients. No complications occurred that were related to the t-PA infusion. No significant prolongation of the prothrombin, thrombin, or activated partial thromboplastin times occurred. At the end of t-PA infusion, the mean circulating fibrinogen level was 59% of the starting value. The therapeutic use of t-PA is still in its preliminary stages and the efficacy and safety of this promising agent need to be further established. From our early experience with t-PA, it appears to be safe as well as effective.

Late results of Coronary Bypass in Patients Presenting with Lower Extremity Ischemia: the Cleveland Clinic Study

Cardiac catheterization was performed in a prospective series of 1000 patients under consideration for elective peripheral vascular reconstruction from 1978-1982. Of these, 381 (mean age 62) presented primarily because of lower extremity ischemia. Severe, surgically correctable coronary artery disease (CAD) was documented in 79 (21%) of the leg group, and 68 (18%) received myocardial revascularization, with three fatal complications (4.4%). In this subset, 39 patients have had uneventful aortoiliac, femoropopliteal or distal extremity procedures, compared to an operative mortality of 23% for 13 others with uncorrected or inoperable CAD (p = 0.015). A total of 286 patients have undergone 407 peripheral vascular operations with eight early deaths (2.8%). An additional 114 patients (30%) died during the late follow-up interval, including 48 (13%) with cardiac events. Both the cumulative 5-year survival (72%) and cardiac mortality (16%) after coronary bypass are superior to comparable figures (21% and 56%, respectively) among 36 other patients with severe, uncorrected or inoperable CAD (p = 0.0001). Five-year survival appears to be improved by myocardial revascularization in men (p = 0.0027), hypertensives (p = 0.0001), nondiabetics (p = 0.0002) and those over 60 years of age (p = 0.0072).

Comparison of Cost Effectiveness of Streptokinase and Urokinase in the Treatment of Deep Vein Thrombosis

This study examines the comparative efficacy, safety, and cost associated with treatment of deep vein thrombosis with streptokinase or urokinase. Sixty patients were analyzed retrospectively, 30 treated with streptokinase and 30 treated with urokinase. Statistically significant greater fibrinogenolysis was noted when streptokinase was used to treat patients with deep venous thrombosis (p = 0.01). The mean decrease in fibrinogen from preinfusion value was 83% in the streptokinase treated group and 61% in the urokinase treated group. Five of 30 (17%) of the streptokinase treated patients experienced major complications. No major complications were seen in the urokinase treated group (p = 0.019). Cost analysis demonstrates that therapy with urokinase was

Coronary artery disease in patients with aortic aneurysm: a classification of 302 coronary angiograms and results of surgical management@@@Enfermedad de la arteria coronaria en pacientes con aneurisma aortico (clasificacion de 302 angiografias coronarias y resultados del tratamiento quirurgico

11.40 per patient more than streptokinase. If complications are not included in the cost analysis, then urokinase becomes only

Evaluation of the patient with leg edema

650 per patient more expensive than streptokinase therapy. These data support that deep vein thrombosis treatment with urokinase is effective, safer and more cost efficient when compared to streptokinase.

Coronary Angiography in 506 Patients With Extracranial Cerebrovascular Disease

In an attempt to reduce early and late mortality caused by myocardial infarction in patients with aortic aneurysms, coronary arteriography and, when indicated, myocardial revascularization were performed prior to elective aortic reconstruction in 302 patients with infrarenal (289) or thoracoabdominal (13) aortic aneurysms. Severe correctable coronary artery disease (CAD) was identified in 31% of the entire series, whereas severe inoperable CAD was seen in another 5%. Severe, correctable CAD was documented in 42% of patients suspected to have CAD by standard clinical criteria and in 19% of those in whom CAD was not suspected. The overall mortality for 89 cardiac and 227 infrarenal aortic surgical procedures was 4,4%. Fatal complications after intrarenal aneurysm resection occurred in only one (1.6%) of 61 patients who had had preliminary myocardial revascularization.ResumenLos autores ya en 1980 demostraron que la lesión coronaria no tratada era la principal causa de mortalidad después de una resección de aneurisma aórtico (AAA), concluyendo que entre los tests de evaluación del enfermo debería incluirse la coronariografía. Desde 1978 a 1982, se consideraron 202 enfermos con AA para tratamiento quirúrgico programdo, efectuándose en todos ellos coronariografía. Había 153 varones y 49 mujeres, con edad media de 67.6 años. En el 7% se diagnosticó una diabetes siendo el principal factor de riesgo la HTA en 166 casos. Entre estos enfermos sólo el 57% tenían un AA aislado, mientras que el resto de pacientes mostraban lesiones multifocales. Los hallazgos por cateterización cardíaca y coronariografía fueron clasificados en los siguientes subgrupos: 1) coronaria normal; 2) coronaria con lesión moderada (estenosis menos del 70%); 3) lesión coronaria avanzada (más del 70%); 4) lesión coronaria severa corregible y 5) con lesión coronaria severa no operable. Esta exploración angiográfica, también demostró que más de la mitad de los pacientes (52%) tenían una lesión operable o bien una lesión tan avanzada que el by-pass aorto-coronario no era posible. Hay que destacar también, que de 144 pacientes sin historia clínica ni cambios electrocardiográficos el 20% tenían una lesión coronaria severa y todos menos uno fueron pontables. 288 enfermos fueron operados por AA infrarrenal, de estos 167 a los que no se les practicó un by-pass aorto-coronario murieron el 4.8%, mientras que de los 61 que sus coronarias fueron pontadas sólo uno morió (1.6%). Por ranzones diversas, en 57 enfermos se siguió un tratamiento conservador y de ellos 11 murieron: 5 después de cirugía cardíaca, 4 de ictus y 2 de fisuración aneurismática mientras esperaban cirugía. El hecho de que sólo hubo un exitus entre los 61 operados de by-pass aorto-coronario, parece probar que la revascularización miocárdica reduce la tasa de mortalidad después de cirugía vascular importante. Persiste sin embargo, la controversia en cuanto al modo de tratar enfermos con lesiones coronarias severas y AA de gran tamaño. Así, mientras que García y cols. abogan por la reconstrucción simultánea coronaria y aórtica (y éste parece ser el método de elección para estos enfermos con lesiones severas coronarias y AA grandes) otros se inclinan por la trombosis intraluminal y el by-pass axilo-fermoral. La información que en la actualidad poseemos en la clínica Cleveland muestra que la supervivencia fue superior en un 29% en aquellos enfermos con lesión coronaria severa corregida con by-pass aortocoronario en comparación con aneurismas, cuyos datos cardíacos no fue investigado (p<0.0001). A pesar de estas cifras, no obstante, no se pueden extraer conclusiones definitivas. Los resultados a largo plazo de este estudio pueden proporcionar nueva información del papel de la revascularización miocárdica en enfermos con AA. Sin embargo, en la actualidad los datos obtenidos parecen aconsejar la coronariografía sistemática en enfermos con sospecha clínica de enfermedad coronaria y que son subsidiarios de resección de AA.