RESUMEN
PURPOSE: To determine the success and complication rates of intraarterial recombinant tissue-type plasminogen activator (rt-PA) infusion for the treatment of acute lower extremity artery and bypass graft occlusions. MATERIALS AND METHODS: The results of 74 limbs in 70 patients (mean age, 66 y) treated with catheter-directed rt-PA infusion for the treatment of acute lower extremity ischemia were retrospectively evaluated. The group included 42 bypass grafts and 32 native arteries. All limbs were viable at presentation. The mean duration of symptoms was 11.9 days. rt-PA was infused for a mean of 27.9 hours for a mean total dose of 38.7 mg. Initial infusion rates of 3-6 mg/h were lowered to a preferred rate of 1.5 mg/h. Thrombolytic success was defined as 95% thrombolysis of an occluded segment with return of antegrade flow. Major bleeding complications were defined as any hemorrhagic event leading to surgery, extended or unexpected hospitalization, transfusion, death, intracranial hemorrhage, or a decrease in hemoglobin of 5 g/dL or in hematocrit of 15%. Thirty-day mortality and amputation rates were calculated. Patient characteristics and infusion parameters were evaluated as to whether they contributed to thrombolytic success or major bleeding events. RESULTS: Thrombolytic success was achieved in 64 limbs (86%). Major bleeding complications occurred in 33 (47%) patients. In 22 of these patients, bleeding occurred at a vascular puncture site, whereas remote bleeding occurred in seven patients. Remote bleeding complications included two retroperitoneal hematomas, two rectus sheath hematomas, one lower gastrointestinal hemorrhage, one episode of hemoptysis, and one dehiscence of a femoral-popliteal bypass graft revision. No parameters were found to be predictive of thrombolytic success, whereas a negative history of smoking, increasing duration of infusion, and a low preprocedural ankle-brachial index (ABI) were found to be associated with major hemorrhagic events. Four patients (6%) underwent amputation and one patient (1%) died, resulting in a 30-day amputation-free survival rate of 93%. CONCLUSION: Catheter-directed rt-PA infusion is effective in achieving thrombolysis. Despite a significant number of bleeding complications, 30-day mortality and amputation rates were favorable. Nonetheless, complication rates related to bleeding were not trivial and further evaluation with use of variable dosing regimens is indicated.
Asunto(s)
Oclusión de Injerto Vascular/tratamiento farmacológico , Isquemia/tratamiento farmacológico , Pierna/irrigación sanguínea , Terapia Trombolítica , Activador de Tejido Plasminógeno/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Femenino , Humanos , Infusiones Intraarteriales , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Terapia Trombolítica/efectos adversos , Activador de Tejido Plasminógeno/efectos adversos , Resultado del TratamientoRESUMEN
PURPOSE: To assess and compare intimal and medial vascular damage caused by three mechanical wall-contact thrombectomy devices: Fogarty embolectomy catheter, Arrow-Trerotola peripheral thrombectomy device, and MTI-Castañeda over-the-wire brush. MATERIALS AND METHODS: Bilateral external iliac arteries of 15 canines were thrombosed before mechanical thrombolysis. Ten thrombosed arteries were randomly assigned to receive each device. Animals were sacrificed immediately, and histologic assessment of endothelial and medial damage in the vessels was performed. RESULTS: The vascular damage found with all devices extended into the tunica media. The Fogarty embolectomy catheter and the Arrow-Trerotola device caused significantly more damage than the Castañeda brush. CONCLUSION: All devices caused lesions extending into the media. Previous research has shown that the extent and depth of the vascular lesion may be contributing factors in promoting early atherosclerotic and accelerated hyperplastic intimal and medial changes. These findings warrant further study of these devices in an atherosclerotic model with longer follow-up.
Asunto(s)
Angiografía , Arteria Ilíaca/lesiones , Trombectomía/instrumentación , Trombosis/terapia , Animales , Cateterismo/instrumentación , Perros , Embolectomía/instrumentación , Endotelio Vascular/diagnóstico por imagen , Endotelio Vascular/lesiones , Diseño de Equipo , Arteria Ilíaca/diagnóstico por imagen , Trombosis/diagnóstico por imagenRESUMEN
PURPOSE: To assess the efficacy, acute endothelial changes, and distal arterial emboli after use of the Cragg thrombolytic brush catheter in mature thrombosed polytetrafluoroethylene (PTFE) femoropopliteal arterial grafts in canines. MATERIALS AND METHODS: PTFE femoropopliteal arterial grafts were implanted in 10 canines and were allowed to mature for approximately 4 weeks. The grafts were thrombosed by mechanical means and allowed to remain thrombosed for 24-72 hours. Through a left carotid cut-down, standard Seldinger arterial puncture was performed, followed by catheterization of the thrombosed graft. A soft, low-speed, brush (6 mm in diameter) aided by preprocedure pulse-spray urokinase infusion was utilized for thrombolysis. The native vessels, just proximal and distal to the anastomosis, were evaluated microscopically for endothelial damage. Arteriography was used for assessment of distal embolus. RESULTS: All grafts were successfully thrombosed before thrombolysis. One graft could not be traversed with a wire and catheter and was, therefore, not treated. Immediate preprocedure pulse-spray urokinase infusion in the remaining nine grafts did not reconstitute antegrade flow in any instance and left significant amounts of residual thrombus in all treated grafts. Mechanical brush thrombolysis reconstituted antegrade flow in all nine treated grafts and complete graft thrombolysis was obtained in most. This was accomplished in a mean time of less than 4 minutes. Emboli were noted angiographically in 67% of cases. Histologic studies showed vessel wall damage limited to the intima or media in 67% of anastomoses. CONCLUSION: This method offers a simple and rapid means of recanalizing thrombosed PTFE femoropopliteal arterial grafts in the studied model. This technique provides a means of rapidly "debulking" most intragraft thrombi. This may result in a shorter course of thrombolytic infusion. Potential benefits may include shortening the total treatment time and decreasing morbidity and cost associated with percutaneous thrombolysis. The occurrence of distal emboli in a majority of cases is a concerning limitation of this technique.
Asunto(s)
Prótesis Vascular , Cateterismo , Arteria Femoral , Politetrafluoroetileno , Arteria Poplítea , Complicaciones Posoperatorias/terapia , Terapia Trombolítica/métodos , Trombosis/terapia , Animales , PerrosRESUMEN
PURPOSE: To assess the safety, efficacy, endothelial changes, and risks of pulmonary embolic events after the use of a new thrombolytic brush catheter in mature thrombosed polytetrafluoroethylene (PTFE) dialysis grafts in an animal model. MATERIALS AND METHODS: Loop configuration PTFE grafts were implanted in the femoral vessels of 12 canines 4 weeks before mechanical thrombosis was performed. The thrombus was allowed to consolidate for 24 hours in 10 animals, 72 hours in one animal, and 7 days in one animal. Standard percutaneous criss-cross catheter access was performed, and a soft, low-speed, brush (6 mm in diameter), aided by 250,000 U of periprocedural urokinase, was utilized for thrombolysis. The native vessels, just distal to the anastomosis, and lungs were evaluated macro- and microscopically. RESULTS: Thrombolysis was complete in all grafts with the exception of a small segment between the crossing of the access vascular sheaths. The total thrombolysis time ranged from 8 to 12 minutes; this included 5 minutes of pulse-spray lacing. No difference in thrombolysis time was found with regard to the age or amount of thrombus. Minimal endothelial changes were noted and no evidence of acute pulmonary embolus was found on necropsy or histologic studies. CONCLUSION: This method offers a simple, safe, and efficient means of recanalization of thrombosed PTFE dialysis grafts in this canine model.
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Prótesis Vascular , Oclusión de Injerto Vascular/tratamiento farmacológico , Politetrafluoroetileno , Terapia Trombolítica/instrumentación , Trombosis/tratamiento farmacológico , Animales , Cateterismo/instrumentación , Perros , Diseño de Equipo , Activadores Plasminogénicos/administración & dosificación , Diálisis Renal , Terapia Trombolítica/métodos , Factores de Tiempo , Activador de Plasminógeno de Tipo Uroquinasa/administración & dosificaciónRESUMEN
PURPOSE: The results and complications of 651 pulmonary fine-needle aspiration biopsies (FNABs) were reviewed. The number of needle passes and needle size were correlated to pneumothorax and chest tube placement rates. MATERIALS AND METHODS: FNAB of the lung was performed on 651 occasions in 612 patients with 18- to 22-gauge Franseen needles. Diagnostic rates were calculated. The number of needle passes performed and needle size used were evaluated for their association with pneumothorax and subsequent chest tube placement. RESULTS: Diagnostic accuracy was 94% with sensitivity for malignancy of 95%. Positive and negative predictive values were 99.5% and 90%, respectively. Pneumothorax occurred in 26.9% of patients with 9.2% requiring chest tube placement. Increasing numbers of needle passes and larger needle sizes did not increase the rates of pneumothorax or chest tube placement. CONCLUSIONS: FNAB of the lung has excellent diagnostic rates and remains the procedure of choice for diagnosing pulmonary lesions. This large study contradicts perceptions that pneumothorax and chest tube placement rates decrease with thinner needles and fewer passes.
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Biopsia con Aguja/efectos adversos , Pulmón/patología , Adulto , Anciano , Anciano de 80 o más Años , Biopsia con Aguja/métodos , Tubos Torácicos , Femenino , Humanos , Neoplasias Pulmonares/diagnóstico , Masculino , Persona de Mediana Edad , Neumotórax/etiología , Neumotórax/terapia , Radiografía Intervencional , Sensibilidad y EspecificidadRESUMEN
Ulnar styloid fractures make up a common component of wrist fractures. In children, fractures of the distal radius often can be subtle. Our retrospective study of 222 children with wrist fractures showed that ulnar styloid fractures seldom occur as isolated injuries. Therefore, they serve as an extremely useful signal for the presence of an associated radial fracture. It was noted that some ulnar styloid fractures remain ununited, giving the appearance of a secondary ossification center of the ulnar styloid process.
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Fracturas del Cúbito/diagnóstico por imagen , Adolescente , Niño , Preescolar , Femenino , Humanos , Lactante , Masculino , Radiografía , Fracturas del Radio/diagnóstico por imagen , Estudios Retrospectivos , Articulación de la Muñeca/diagnóstico por imagenRESUMEN
A panel of nine monoclonal antibodies has been produced against a major nuclear protein, B-36, purified from the slime mold Physarum polycephalum. B-36, a 34 kD protein biochemically similar to the major structural proteins of mammalian hnRNP particles, was previously shown to be largely associated with the nucleolus. Eight of the monoclonal antibodies are specific for B-36 protein in Physarum and at least three different epitopes are represented among these eight. Using the monoclonal antibodies B-36 has been shown to be localized exclusively to the nucleolus in actively-growing Physarum cultures. The nucleolar localization of B-36 is dependent on the presence of intact RNA, but not DNA, supporting the hypothesis that B-36 is associated with nucleolar RNA, possibly in some analogous manner to the interaction of the related proteins within heterogeneous nuclear ribonucleoproteins (hnRNP) particles. B-36 is apparently a highly conserved nucleolar protein in eukaryotes as all eight of the monoclonal antibodies specific for B-36 in Physarum are also specific for a 34.5 kD nucleolar protein in rat liver. This indicates that a minimum of three distinct epitopes are conserved in B-36 protein from slime mold to rat.