Intra-arterial injection, a rare but serious complication of sclerotherapy

Intra-arterial injections represent the most feared complication of sclerotherapy for varicose veins. We present a case of an inadvertent intra-arterial injection of polidocanol at the left medial calf in a 59-year-old woman with subsequent arterial occlusions of the posterior tibial artery and foot arteries. Despite several therapeutic interventions, lower-limb amputation could not be prevented. We conducted a PubMed search for articles reporting arterial complications related to sclerotherapy, in order to evaluate aetiology, clinical presentation, therapeutic management and outcome of sclerotherapy-associated intra-arterial injections during the past 50 years. Intra-arterial injection of a sclerosing solution was reported in 63 cases, mostly after injection near the ankle region or the distal medial calf. Clinical presentation was frequently characterized by immediate pain during injection and distal ischaemia with subsequent tissue loss. Despite several treatment approaches, amputation could not be prevented in 31 cases (52.5%). The pathophysiology of arterial complications related to intra-arterial injection and advisable therapeutic interventions are discussed. Inadvertent intra-arterial injection represents a limb-threatening complication of sclerotherapy. Target-oriented and prompt therapy seems inevitable in order to reduce the risk of permanent tissue loss and amputation.

Unusual deep vein thrombosis sites: magnetic resonance venography in patients with negative compression ultrasound and symptomatic pulmonary embolism

OBJECTIVES

To evaluate the clinical characteristics of patients with pulmonary embolism (PE), negative compression ultrasound (CUS) of the lower limbs and detection of unusual deep vein thrombosis (DVT) sites by means of magnetic resonance (MR) venography.

METHODS

A retrospective data analysis of PE patients hospitalized at our institution from April 2009 to 2011.

RESULTS

From April 2009 to 2011, a total of 762 PE patients were treated at our institution. In 169 of these patients CUS for DVT was negative. In these patients MR venography was performed for further evaluation. We found venous thrombosis at unusual sites in 12 of these patients. Due to free floating thrombus masses and fear of life-threatening PE progression we inserted an inferior vena cava filter in three of these 12 patients. The leading venous thromboembolism risk factor in our patients was immobilization (5 patients, 41.7%).

CONCLUSIONS

We conclude that especially in patients with PE and negative CUS of the lower limbs a thrombosis of the pelvic veins should be considered in case of symptoms for venous thrombosis in this area. Further diagnostic work-up with MR venography should be scheduled in these patients especially in patients with risk factor immobilization as therapeutic consequences might occur.

Dabigatran in patients with atrial fibrillation: perioperative and periinterventional management

In any type of invasive surgery, the patient’s individual risk of thromboembolism has to be weighed against the risk of bleeding. Based on various everyday situations in clinical routine, the purpose of the present expert recommendations is to provide appropriate perioperative and periinterventional management for patients with atrial fibrillation undergoing long-term treatment with the thrombin inhibitor dabigatran. As we currently have no routine laboratory test to measure therapeutic levels of the substance or the risk of bleeding, general measures such as a standardized documentation of the patient’s history, a sufficient time interval between the last preoperative dose and the procedure, and careful control of local hemostasis should be given special attention.

Impaired endothelial-dependent and endothelium-independent vasodilatation in patients with thromboangiitis obliterans

BACKGROUND

Endothelial dysfunction is the key process in the development of atherosclerosis. The aim of our study was to evaluate endothelial dysfunction measured by the noninvasive technique of Celermajer that plays a role in the pathogenesis of thrombangitis obliterans.

METHODS

A total of 36 patients with thrombangitiis obliterans ([TAO]; mean age 44.9 ± 1.3 years) were compared with 30 healthy individuals (mean age 36.1 ± 1.8 years). High frequency ultrasound was used to measure changes in response to reactive hyperemia (leading to flow-mediated endothelium-dependent dilatation) and in response to 0.4 mg sublingual nitroglycerin ([NTG]; leading to NTG-induced, endothelium-independent dilatation).

RESULTS

Patients with TAO showed a lower but statistically not significant flow-mediated dilatation and a statistically significant reduced NTG-induced vasodilatation than the control group.

CONCLUSION

Our results suggest that both mechanisms play a role in patients with TAO, the endothelium-independent impaired vasodilatation even in a more significant way than the impaired endothelium-dependent vasodilatation.

Cystic medial necrosis Erdheim Gsell as a rare reason for spontaneous rupture of the ascending aorta

Spontaneous rupture of the ascending aorta is a life-threatening condition requiring immediate intervention. The rupture usually leads to sudden death as a result of hemopericardium or hemothorax. The underlying histopathological condition in the cases described so far was mostly an atheromatous plaque. Some other rare underlying conditions were also described. We report a case of cystic medial necrosis Erdheim Gsell as a reason for fatal spontaneous rupture of the ascending aorta.

Proximal lower limb vein thrombosis following vipera berus hand bite

Vipera berus has a wide geographical distribution throughout Central and Northern Europe. The symptoms after a bite usually are mild, life threatening symptoms are mainly described in children. We describe a case of popliteal vein thrombosis of the right leg after systemic envenoming with Vipera berus venom after a bite in the right hand by a female Vipera berus in the alpine region of Styria, Austria. Changes of the plasmatic coagulation system were obvious in our patient. These changes were due to an activation of the coagulation system and might be the reason for the thrombotic event in this usually healthy young male person.

Massive pulmonary embolism in spite of temporary vena caval filter

Anticoagulation still remains the primary therapy for venous thromboembolism (VTE) in order to prevent the most life-threatening form of VTE, pulmonary embolism (PE). Nevertheless in some patients anticoagulation is impossible. Then vena caval filters serve as a valuable second line therapy against the most feared complication of VTE, fatal PE. We want to present a patient with preceding PE and DVT in whom for the perioperative period a temporary vena caval filter was placed and who showed the complication of a nearly fatal PE. A seventy-two year-old white male was admitted for thrombolytic therapy for massive pulmonary embolism, which was performed successfully. Some hours later the patient developed gastrointestinal bleeding. An adenocarcinoma of the colon was diagnosed and an end-to-end hemicolectomy performed. A temporal caval filter (Gunther filter) was placed in the infrarenal vena cava for the perioperative period. Seven days later the patient syncopated with acute massive onset of dyspnea. A helix computertomography scan of the lung showed again massive central pulmonary embolism with right heart enlargement. An immediate pulmonary embolectomy had to be performed. Subsequent venal cavography revealed a thrombosed vena caval filter and a thrombus proximal to the filter. This case report should emphasize the fact that although a vena cava filter might be of high benefit in patients with contraindication for anticoagulation to prevent recurrent PE, in some cases it can be insufficient and lead to enormous complications.

The evaluation of the no-independent vasodilatative effect of iloprost in isolated perfused Guinea pig hind limbs

AIM

In critical limb ischemia vasodilatators play an important role in the treatment of the disease. Considering that the endothelium is seriously damaged in these patients, we wanted to evaluate if the vasodilatative effect of iloprost does or does not depend on the endothelium by using the model of the isolated perfused guinea pig hind limb.

METHODS

A catheter was inserted via the distal aorta and common iliac artery. After stabilization, iloprost was administered at a dosage of 0.1 microM. In a subsequent series of experiments precontraction of the peripheral vascular bed was achieved with 40 mM KCl followed by 0.1 microM iloprost. In a 3rd series of experiments L-NAME (100 microM) was administered after the equilibration period for 30 minutes, followed by 0.1 microM iloprost. In the 4th series of experiments, after the administration of L-NAME (100 microM), KCl (40 mM) was administered to precontract the vascular bed and iloprost 0.1 microM was added.

RESULTS

The administration of iloprost alone and after addition of KCL induced a significant decrease in vascular resistance(-49.6+/-14.1% [x+/-SEM, n=7]). The addition of L-NAME did not affect vascular resistance. The consecutive addition of iloprost reduced vascular resistance significantly (-4.2+/-0.7% [x+/-SEM, n=7]). After addition of L-NAME 100 microM and precontraction with KCl 40 mM, iloprost once again significantly reduced peripheral vascular resistance (-51.5+/-14.4% [x+/-SEM, n=6]). Reduction of peripheral vascular resistance by iloprost was comparable to that without L-NAME.

CONCLUSION

Our data show that iloprost at a dosage of 0.1 microM achieves a significant reduction in peripheral vascular resistance and that the vasodilatative effect of iloprost is independent of NO. Iloprost therefore seems to be an ideal vasodilatative drug for the treatment of patients with impaired endothelial function.

The role of 2-18F-fluoro-2-deoxy-D-glucose positron emission tomography in the diagnosis of giant cell arteritis of the temporal arteries

OBJECTIVE

As one of the diagnostic criteria for giant cell arteritis affecting the temporal arteries (temporal arteritis) is still biopsy-proven vasculitis of the affected artery, the aim of our study was to evaluate the value of a non-invasive procedure, 2-(18)F-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (F-18-FDG-PET), in the diagnosis of Horton's disease.

METHODS

During a period of 10 months, 22 consecutive patients with the clinical diagnosis of giant cell arteritis and a positive hypoechogenic halo in duplex sonography were re-examined with F-18-FDG-PET. Six patients had giant cell arteritis involving both the large arteries and the temporal arteries; five patients showed giant cell arteritis only in the large arteries without concomitant involvement of the temporal arteries, and the remaining 11 patients showed only involvement of the temporal arteries. All patients were examined by sonography and F-18-FDG-PET, which was performed before treatment with corticosteroids.

RESULTS

All patients with positive signs of giant cell arteritis in duplex sonography, i.e. a hypoechogenic halo in the large arteries (thoracic, subclavian, axillary, iliac, aorta), also showed elevated FDG uptake in the same vessels, with complete agreement in the anatomical distribution of changes. When positive sonography was limited to the temporal arteries, FDG-PET was completely negative in the temporal arteries and all other arterial locations.

CONCLUSION

PET is not yet suitable for the diagnosis of temporal arteritis and therefore cannot replace invasive biopsy. F-18-FDG-PET is well suited to the demonstration of giant cell arteritis in arteries exceeding 4 mm in diameter.

Genetic evaluation of the common variant of the endothelial nitric oxide synthase (Glu(298)-><Asp) in patients with thromboangiitis obliterans

BACKGROUND

Nitric oxide is synthesized by endothelial nitric oxide synthase and plays a key role in adequate endothelial function. An important effect is the reduction of free radicals caused by cigarette smoking, which is the only established risk factor for thromboangiitis obliterans (TAO). In patients with TAO a genetic defect of endothelial nitric oxide synthase may therefore result in deteriorated endothelial function. The aim of our study was to evaluate whether a genetic defect of the common variant of endothelial nitric oxide synthase (Glu(298)-->Asp) can be found in a higher degree in patients with TAO compared to healthy controls.

METHODS

We enrolled 42 patients with TAO and 149 healthy subjects.

RESULTS

Nineteen patients (45.2%) showed homozygosity for Glu(298) versus 76 (51%) in the control group. The heterozygous status for Glu(298)-->Asp was found among 18 patients (42.9%) compared to 61 (40.9%) members of the control group, which was a nearly equal distribution. Homozygosity for the mutant Asp(298) was slightly elevated in the patient group with 11.9 versus 8.1% in the control group. Allele frequency for Asp(298) was 0.333.

CONCLUSIONS

Our data do not show elevated homozygosity for the common variant Glu(298)-->Asp in patients with TAO compared to healthy controls. The limitation of our evaluation is the small number of patients, which is a general problem when evaluating patients with TAO, as this is not a common disease.