Effect of Iloprost infusion on metabolism in critical limb ischemia, utilizing microdialysis. A pilot study

AIM

In critical limb ischemia (CLI), the prognosis to keep the leg is poor if revascularisation is not possible. Treatment with prostanoids has proven to be beneficial regarding pain relief, ulcer healing and limb salvage but only in a proportion of patients. Prostanoids exert their effect in different ways e.g. on white blood cells and endothelial cells. No study has so far investigated the effect of prostanoids on the local tissue metabolism. The aim of this study was to investigate if infusion of the prostacyclin analogue, iloprost (PGI2) improves the local metabolism measured by microdialysis technique.

METHODS

Eleven patients, 7 men and 4 women, median age 75 years (range 64-89 years), suffering CLI (Fontaine stage III and IV), were included. Patients with insulin dependent diabetes mellitus were excluded. Microdialysis catheters (CMA 60) were inserted subcutaneously in the ischemic leg and in the pectoral region, respectively. An iloprost infusion was given for 6 hours during 3 days preceded by a control day. Registrations of glucose and lactate levels were performed hourly.

RESULTS

No significant differences were found in lactate or glucose levels over the treatment period but a trend of increasing glucose and decreasing lactate was observed. Compared to the control day, lactate was significantly lower during (p=0.02) and after (p<0.05) the infusion. This was also true for the reference catheter during the infusion period (p=0.02).

CONCLUSIONS

No immediate improvement in glucose or lactate levels in ischemic tissue could be observed after 3 days of iloprost infusion, but a significant lactate decrease was found compared to a previous control day, suggesting a possible metabolic response.

White blood cell and endothelial cell response to endovascular procedures in the leg

AIM

The longterm patency of endovascular procedures is partly depending on restenosis by intimal hyperplasia, a process depending on inflammatory mechanisms resembling the mechanisms of normal repair and the process of atherosclerosis. The aim of this study was to characterize the inflammatory response of white blood cells (WBC) and endothelial cells following endovascular procedures in the leg.

METHODS

Venous blood samples were drawn from a cubital vein before and 2 hours after intervention in 19 patients suffering from peripheral arterial occlusive disease (PAOD). Flow cytometry was used to identify and determine the concentrations of WBC and platelets and to measure CD11b/CD18 on WBC and CD41 on platelets. Soluble endothelial markers (sICAM-1, sE-selectin, sP-selectin and sVCAM-1) were measured by ELISA technique.

RESULTS

WBC were downregulated following endovascular procedures. The endothelial cell response was limited and only downregulation of sP-selectin reached significant levels. The results were more evident in the group of patients with critical limb ischemia (CLI) compared to patients with intermittent claudication (IC).

CONCLUSION

Endovascular procedures in the leg evoke only a limited response which is depending on the degree of ischemia and the magnitude of the interventional procedure.

Postoperative on-line monitoring with intraperitoneal microdialysis is a sensitive clinical method for measuring increased anaerobic metabolism that correlates to the cytokine response

BACKGROUND

Visceral ischaemia and cytokine release are early stages in the development of shock and multiorgan failure. Because of lack of methods to measure anaerobic metabolism or visceral hypoxia in the early phase, diagnosis is not usually established until shock and organ failure are evident.

METHODS

Nineteen patients were studied postoperatively after major abdominal gastrointestinal surgery. A microdialysis catheter was placed intraperitoneally before closure of the abdomen. Analysis of glucose, pyruvate and lactate was performed every second hour and the ratio between lactate and pyruvate was calculated. Peritoneal fluid was collected from a peritoneal drainage for analysis of tumour necrosis factor alpha (TNF-alpha) and interleukin 10 (IL-10).

RESULTS

Sixteen of the patients had a normal postoperative course; the lactate/pyruvate ratio started at the level of 20 immediately postoperatively and decreased significantly during the first 45 postoperative hours (P = 0.007). A similar pattern was recorded for peritoneal TNF-alpha, which decreased correspondingly (P = 0.003). A correlation coefficient of 0.303 (P < 0.001 ) between lactate/pyruvate ratio and TNF-alpha was found. After an initial short increase, IL-10 decreased over time (P < 0.001). Three of the patients had abnormalities in the microdialysis results, cytokines and clinical outcome. These patients are presented separately.

CONCLUSIONS

A normal postoperative course results in a decrease in the intraperitoneal lactate/pyruvate ratio, TNF-alpha and IL-10. A correlation between the intraperitoneal lactate/pyruvate ratio and TNF-alpha was found which suggests that intraperitoneal microdialysis is a sensitive, indirect method in analysing the postoperative intraperitoneal inflammatory response. A complicated postoperative course was preceded by increase of the peritoneal lactate/pyruvate ratio interpreted as splanchnic hypoxia and also an increased TNF-alpha level.

Long-term results after endovascular repair of abdominal aortic aneurysms with the Stentor and Vanguard stent-graft

PURPOSE

To present a single institution experience of long-term results after endovascular repair of abdominal aortic aneurysms (AAA) with the Stentor and Vanguard stent-grafts.

MATERIAL AND METHODS

Twenty-three patients (20 men, 3 women; mean age 68 years, range 53-81 years) were included in this prospective study. A first generation nitinol stent-graft (Stentor) was used in 12 patients and a second generation (Vanguard) in 11 patients. Follow-up was performed with magnetic resonance imaging (MRI) with contrast-enhanced MR angiography (CE MRA) at 1, 6, and 12 months, and thereafter annually (median follow-up 3 years; range 8 months to 8 years). A conventional radiograph of the abdomen was also performed. Before secondary intervention the findings on MRI with CE MRA were confirmed with spiral computed tomography (CT) and/or angiography (DSA).

RESULTS

Only one patient (4%) had no complication. Endoleak was found in 15 patients (65%), graft migration in 8 (35%), and graft deformation in 18 (78%). Secondary endovascular repair was required in 7 patients (30%) and 7 (30%) were converted to open repair.

CONCLUSION

Complications with the Stentor and Vanguard stent-grafts were common. Long-term follow-up of endovascularly repaired AAA is mandatory.

Patient preferences for follow-up methods after endovascular repair of abdominal aortic aneurysms

AIM

A fundamental and influential difference between open and endovascular repair of abdominal aortic aneurysms is the central role of imaging after endovascular repair. Willingness of the patient to return for further imaging is an important factor in choosing the method for follow-up. This study was undertaken to assess the subjective experiences of patients undergoing magnetic resonance imaging with contrast enhanced MR angiography, computed tomography and angiography (DSA) after endovascular repair of abdominal aortic aneurysms.

METHODS

In a prospective study, 24 consecutive patients after endovascular repair of abdominal aortic aneurysms were invited to answer a questionnaire to qualitatively investigate the patient preferences for the follow-up methods, magnetic resonance imaging with contrast enhanced MR angiography, computed tomography and DSA. Nineteen patients (79%) answered. The questionnaire was constructed according to the principles and methods in nursing research and was developed as closed-ended multiple-choice questions with 4 alternatives, from most favorable to least favorable. The items of the questionnaire were based on interviews with radiographers in charge of each modality and concerned the most common patient experiences.

RESULTS

The overall patient experience of magnetic resonance imaging with contrast enhanced MR angiography was more unpleasant than computed tomography.

CONCLUSION

The overall patient experience showed no differences between magnetic resonance imaging with contrast enhanced MR angiography and DSA, or between computed tomography and DSA.

A clinical approach to the management of a patient with suspected renovascular disease who presents with leg ischemia

Atherosclerotic renal artery stenosis (ARAS) may cause hypertension, progressive renal failure, and recurrent pulmonary edema. It typically occurs in high risk patients with coexistent vascular disease elsewhere. Most patients with ARAS are likely to die from coronary heart disease or stroke before end-stage renal failure occurs. Recent controlled trials have shown that most patients undergoing angioplasty to treat renovascular hypertension still need antihypertensive agents 6 or 12 months after the procedure. Nevertheless, the number of antihypertensive agents required to control blood pressure adequately is lower following angioplasty than for medication alone. Trials assessing the value of revascularization for preserving renal function or preventing clinical events are only in the early recruitment phase. Revascularization should be undertaken in patients with ARAS and resistant hypertension or heart failure, and probably in those with rapidly deteriorating renal function or with an increase in plasma creatinine levels during angiotensin-converting enzyme inhibition. With or without revascularization, medical therapy using antihypertensive, hypolipidemic and antiplatelet agents is necessary in almost all cases.

Human intraperitoneal microdialysis: increased lactate/pyruvate ratio suggests early visceral ischaemia. A pilot study

BACKGROUND

Previous studies suggest that visceral ischaemia precedes shock and multiple organ failure, though methods for studying humans are lacking. We aimed to evaluate intraperitoneal microdialysis, a new technique for detecting splanchnic ischaemia in clinical practice.

METHODS

Right-sided hemicolectomy was performed in eight patients who were studied by microdialysis postoperatively for glucose, lactate, pyruvate and glycerol levels.

RESULTS

Six of the eight patients showed a normal postoperative course and had lactate/pyruvate ratios between 7.1 and 21.7, glucose between 4.5 and 14.3 mmol/L and glycerol between 10.4 and 296 micromol/L. In one patient, intraperitoneal lactate/pyruvate ratio and glycerol increased and glucose decreased 5 h before low oxygenation appeared. Another patient exhibited a period of increased lactate/pyruvate ratio before a period of atrial fibrillation.

CONCLUSION

Intraperitoneal microdialysis was performed safely. Two out of the eight patients exhibited changes of metabolic markers followed by clinical symptoms that were probably related to transient visceral ischaemia. Our findings suggest that intraperitoneal microdialysis may become a useful tool for monitoring splanchnic ischaemia in clinical practice.

Global venous function correlates better than duplex derived reflux to clinical class in the evaluation of chronic venous disease

AIM

To compare the symptoms and signs of patients with chronic venous disease with the objective results of duplex ultrasound and plethysmography (foot volumetry).

METHODS

One hundred and one patients with symptomatic chronic venous disease were investigated with duplex ultrasound and foot volumetry. Patients were classified according to the CEAP classification and the symptoms of pain, heaviness, tiredness, ankle swelling and night cramps were graded. The severity of the disease was judged objectively by the reflux time (sum of reflux time at 6 levels) and the venous function was measured globally with expelled volume (ml) and refilling rate (Q) (ml/100 mlxmin) after exercise, and expelled volume related to foot volume (EVrel), (ml/100 ml). The ratio Q/EVrel)was calculated. Correlation was calculated between clinical class, symptoms and objective parameters.

RESULTS

The correlation analyses showed a clear constant relationship between the CEAP clinical classification and the foot volumetry measures (Q/EVrel), r=0.48; p<0.01) There was no such relationship between clinical class and the sum of duplex calculated reflux time (r=-0.05), or between foot volumetry and reflux time. There was no correlation between the clinical class and the total score of symptoms (r=0.044).

CONCLUSION

The clinical class of CEAP classification correlates significantly with foot volumetry parameters. There is no correlation between clinical class and reflux time. The severity of the venous disorder and subsequently the need for treatment is more accurately judged by foot volumetry as a global measure. Clinical classification has a realistic meaning concerning the functional evaluation of venous disease.

Enoxaparin effect depends on body-weight and current doses may be inadequate in obese patients

Potential problem highlighted

Microdialysate metabolites before, during and after vascular surgery for chronic leg ischaemia

OBJECTIVE

to investigate peripheral metabolism in the leg during bypass surgery for chronic ischaemia.

PATIENTS AND METHODS

in eight patients, microdialysis catheters were placed in the anterior and posterior tibial muscles, subcutaneously in the leg and, for reference, subcutaneously in the pectoral region. Tissue glucose, glycerol and lactate levels were measured between induction of anaesthesia and the first postoperative day.

RESULTS

glucose levels increased postoperatively at all four sites. Glycerol levels decreased during the day of surgery. Glycerol was significantly lower in the leg than in the pectoral region. Muscle lactate increased after anaesthesia, but before proximal clamping, and no further significant intra-operative increase was observed. Post-operatively, lactate decreased to baseline levels. Subcutaneous lactate levels followed the changes observed in muscle but did not reach statistical significance.

CONCLUSION

bypass surgery for chronic ischaemia temporarily worsens ischaemic metabolism in the leg.

Measurements before endovascular repair of abdominal aortic aneurysms. MR imaging with MRA vs. angiography and CT

PURPOSE

1) To compare measurements obtained with MR imaging (MRI)/contrast-enhanced MR angiography (CE MRA) with measurements obtained with angiography (DSA) and CT, for stent-graft sizing of abdominal aortic aneurysms (AAA). 2) To compare MRA measurements obtained with the two post processing techniques MIP (maximum intensity projection) and VRT (3D volume rendering technique).

MATERIAL AND METHODS

The prospective study included 20 consecutive patients with AAA identified by DSA and CT as suitable for endovascular repair. For the study, MRI/CE MRA was performed. Five measurement variables for stent-graft sizing were chosen. Comparisons were made between MRI/CE MRA, DSA and CT, and between observers. Comparisons were also made between MIP and VRT.

RESULTS

Significantly shorter lengths were obtained with MRA-MIP than with DSA. Three out of six diameter measurements were significantly smaller on MRI/CE MRA than on DSA and CT. No significant differences were found between the observers. One diameter measurement was significantly smaller on MIP than on VRT, while the other measurements showed no significant differences.

CONCLUSION

The length measurements obtained with MRA-MIP were probably more correct than those with DSA. For more reliable diameter measurements with CE MRA, improvements of the technique, including VRT reconstructions and a standardized determination of the vessel boundaries, are needed.

Costs in follow-up of endovascularly repaired abdominal aortic aneurysms. Magnetic resonance imaging with MR angiography versus EUROSTAR protocols

AIM

Endovascular repair of abdominal aortic aneurysms (AAA) necessitates a long-term follow-up. These patients are often old and renal insufficiency is not unusual. Cost-effectiveness needs to be addressed in evaluating methods of follow-up. The aim of this study was to compare costs of 5 years follow-up with magnetic resonance imaging with contrast enhanced three-dimensional magnetic resonance angiography (MRI/MRA) with follow-up using CT with DSA, or CTA. We also assessed the impact of contrast media induced (CMI) nephropathy on follow-up costs.

METHODS

We have implemented Swedish costs of CT with DSA, and CTA on the reported follow-up examinations from the EUROSTAR progress report 2000. The costs of follow-up with CT with DSA, or CTA were compared to a follow-up protocol with MRI/MRA. A cost analysis including a risk analysis of CMI nephropathy was made between MRI/MRA and CT with DSA, or CTA.

RESULTS

Excluding the risk of CMI nephropathy, the 5 years follow-up cost in Euro ( ) with MRI/MRA ( 5715) is substantially higher than CT with DSA ( 3 095) or CTA ( 3573). The cost analysis favours MRI/MRA if the risk of CMI nephropathy from CT with DSA, or CTA is more than 5%.

CONCLUSION

MRI/MRA can be cost-effective for follow-up of endovascularly repaired AAA depending on the risk of CMI nephropathy for CT with DSA, and CTA. MRI/MRA should be the method of choice for patients with pre-existing renal insufficiency.

Measurements before endovascular repair of abdominal aortic aneurysms. MR imaging with MRA vs. angiography and CT

PURPOSE

1) To compare measurements obtained with MR imaging (MRI)/contrast-enhanced MR angiography (CE MRA) with measurements obtained with angiography (DSA) and CT, for stent-graft sizing of abdominal aortic aneurysms (AAA). 2) To compare MRA measurements obtained with the two post processing techniques MIP (maximum intensity projection) and VRT (3D volume rendering technique).

MATERIAL AND METHODS

The prospective study included 20 consecutive patients with AAA identified by DSA and CT as suitable for endovascular repair. For the study, MRI/CE MRA was performed. Five measurement variables for stent-graft sizing were chosen. Comparisons were made between MRI/CE MRA, DSA and CT, and between observers. Comparisons were also made between MIP and VRT.

RESULTS

Significantly shorter lengths were obtained with MRA-MIP than with DSA. Three out of six diameter measurements were significantly smaller on MRI/CE MRA than on DSA and CT. No significant differences were found between the observers. One diameter measurement was significantly smaller on MIP than on VRT, while the other measurements showed no significant differences.

CONCLUSION

The length measurements obtained with MRA-MIP were probably more correct than those with DSA. For more reliable diameter measurements with CE MRA, improvements of the technique, including VRT reconstructions and a standardized determination of the vessel boundaries, are needed.

Outcome of treatment of ruptured abdominal aortic aneurysms depending on the type of hospital

OBJECTIVE

To compare the outcome of patients operated on acutely for ruptured abdominal aortic aneurysms (AAA) or otherwise symptomatic aortic aneurysms in a university hospital and in two county hospitals by the same group of vascular surgeons.

DESIGN

Retrospective study.

SETTING

1 university and 2 county hospitals, Sweden.

SUBJECTS

108 patients operated on urgently for AAA, 81 at the university hospital, and 27 at the county hospitals between January 1992 and December 1998.

INTERVENTION

Repair of the AAA.

MAIN OUTCOME MEASURES

Morbidity and mortality.

RESULTS

21 of the 81 patients having urgent repair of an AAA at the university hospital (26%) had been transferred from the county hospitals. Thirteen patients were not operated on, 7 because of their poor general condition and great age (median 84 years), 3 who refused operation, and 3 in whom the diagnosis was incorrect. During the same time period a further 27 haemodynamically unstable patients were operated on by the same vascular surgeons at the county hospitals. The on-table mortality for patients with ruptured AAA and shock was 5/43 (12%) at the university hospital and 4/27 (15%) at the county hospitals. The corresponding in-hospital rates were 11/43 (26%) and 11/27 (41%). Mortality was significantly higher if the operation was delayed by more than 45 minutes. The incidence of postoperative complications was the same in both hospitals.

CONCLUSION

If a patient with a ruptured AAA and shock is admitted to the county hospital and operated on by a specialist vascular surgeon the outcome is fully acceptable. The difference seems to be related to the postoperative period. To what extent the delay caused by the surgeon's journey to the county hospital has any influence on the outcome is not possible to evaluate.

Peripheral arterial disease. Contrast-enhanced 3D MR angiography of the lower leg and foot compared with conventional angiography

PURPOSE

To determine whether contrast-enhanced 3D MR angiography (CE MRA) could replace digital subtraction angiography (DSA) for the evaluation of atherosclerotic peripheral vascular disease of the lower leg and foot.

MATERIAL AND METHODS

Thirty-five patients with symptoms of atherosclerotic disease of the leg were examined prospectively with CE MRA of the foot and the lower legs as well as with DSA from the aorta to the pedal arches. The MRA technique was focused on optimal imaging of the arteries of the foot.

RESULTS

The agreement between CE MRA and DSA for grading of stenosis was moderate to good (weighted kappa-values 0.48-0.80). The sensitivity of CE MRA for detection of significant stenosis (> or = 50%) was 92% and the specificity was 64% with DSA as gold standard.

CONCLUSION

CE MRA is a fairly accurate method for the demonstration of atherosclerotic disease below the knee including the pedal arches. It can replace DSA for the assessment of distal arteries in patients with impaired renal function. However, image quality and resolution still needs to be improved before CE MRA can become the method of choice in all patients.

A randomised controlled trial of micronised purified flavonoid fraction vs placebo in patients with chronic venous disease

OBJECTIVE

to evaluate the efficacy of a micronised purified flavonoid fraction (MPFF) in the treatment of chronic venous disease (CVD).

DESIGN

prospective double blind, randomised, control study.

PATIENTS AND METHODS

one hundred and one patients with symptomatic CVD were randomly allocated to treatment for 60 days with either MPFF (51 patients) or placebo (50 patients) 500 mg twice daily. There were 28 men and 73 women, aged 22-65 years (mean age 48 years). No difference regarding age, gender, clinical class or duration of symptoms was recorded between the treatment and placebo groups. A global score for evaluation of symptoms was used. Patients were investigated with plethysmography (foot-volumetry) and duplex-ultrasonography before and after the treatment period. For statistical comparison Cochran-Mantel-Haenszel test, two-sided Student t-test and covariance analysis were used and p<0.05 was regarded significant.

RESULTS

improvement of the global score of symptoms was reported by 21 patients in the MPFF group and by 16 in the placebo group (N.S.). For the whole groups, no significant differences were recorded before and after treatment regarding foot-volumetric or ultrasonographic parameters. On the other hand, in patients with edema (20 in the MPFF group, 23 in the placebo group) ultrasonographic reflux time was significantly reduced for those in the treatment group (p=0.03). This finding did not correlate to clinical symptoms.

CONCLUSION

in this study, MPFF did not change the symptoms of CVD, except night cramps. A secondary finding was reduced reflux times in patients with oedema, although no ultrasonographic or foot-volumetric parameters changed significantly for the whole group. The role of MPFF in treatment of patients with CVD needs to be further analysed in a large population.

Spinal cord metabolism during thoracic aortic cross-clamping in pigs with special reference to the effect of allopurinol

OBJECTIVE

investigate the metabolic response of the spinal cord and the effect of allopurinol following cross clamping of the descending thoracic aorta in a porcine model.

DESIGN

experimental animal study.

MATERIALS

twelve domestic swine. Six pigs were pre-treated with allopurinol, while six pigs served as controls.

METHODS

measurement of extracellular concentrations of glucose, pyruvate, lactate, glycerol and glutamate using microdialysis in the lumbar spinal cord. Measurement of lumbar spinal blood flow using laser Doppler technique.

RESULTS

for all animals there was a significant decrease in concentrations of glucose and pyruvate together with a significant increase in the lactate-pyruvate ratio during aortic cross clamping. There was also a significant increase in glycerol concentrations 60 min after cross clamping, and a significant decrease in glutamate concentrations after 50 min. No differences in concentrations of glucose, pyruvate, lactate and glutamate or the glutamate-pyruvate ratio were observed between animals used as controls and those treated with allopurinol. The laser Doppler flux decreased to 40% of pre cross-clamp level, returning to normal values at declamping.

CONCLUSION

the changes in energy-related metabolites reflect a considerable ischaemia in the spinal cord tissue but there was no convincing effect of allopurinol on the lumbar spinal cord metabolism during thoracic aortic cross clamping in this model.

The Inflammatory Response and its Consequence for the Clinical Outcome Following Aortic Aneurysm Repair

OBJECTIVE

to review published studies on the outcome of the inflammatory response after abdominal aortic aneurysm (AAA) repair.

METHODS

a literature search on PubMed was performed. All studies that determined the inflammatory response (cytokine release) after AAA repair were included. The results of the studies and differences between open and endoluminal repair were compared and evaluated.

RESULTS

seventeen studies were identified. In most studies the investigated cytokines were TNF-alpha and IL-6. Determination of IL-1 beta, IL-8, TNFsr1 and TNFsr2 were less often performed. TNF-alpha may reflect, but not strictly predict, the clinical outcome in patients with ruptured AAA. IL-6 levels correlate well with the surgical trauma per se. Variations in recorded cytokine release during endovascular AAA repair may depend on the times of blood sampling.

CONCLUSION

both open and endovascular AAA repair provoke a cytokine response. This response is greater during open repair than during endovascular aortic aneurysm exclusion.

Percutaneous Transluminal Angioplasty of Crural Arteries: Diabetes and other Factors Influencing Outcome

OBJECTIVE

to evaluate the efficacy of percutaneous transluminal angioplasty (PTA) of the crural arteries.

PATIENTS AND METHODS

a retrospective review of patients treated with PTA of at least one crural artery during an 8-year period (1990--1997).

RESULTS

one hundred and fifty-five legs in 140 consecutive patients (mean age 74 years, range 38--91 years) were treated. In 76% a more proximal lesion was also treated. After 1 year, results were significantly better in non-diabetics (improvement rate of 66% vs 32%p <0.05). The outcome for patients with a combination of diabetes, heart disease and renal disease was significantly worse compared to all other patients with an improvement rate of only 9% after 1 year. Patients alive and not amputated at 1 year were significantly more common (p <0.05) among non-diabetics (90%), compared to diabetics (66%). The 1-year mortality for the whole group was 15%, significantly higher for diabetic patients (p =0.04).

CONCLUSION

PTA of crural arteries produces reasonably good results in non-diabetic patients. Diabetic patients were doing worse than non-diabetics after a year, though 1-month results were not significantly different. Patients with diabetes, heart disease and renal disease make a high-risk group that has a significantly worse outcome.

Regional Tissue Metabolism During Open or Endovascular Abdominal Aortic Aneurysm Surgery

OBJECTIVE

to investigate differences in regional tissue metabolism between open and endovascular aneurysm repair utilising a microdialysis technique.

MATERIALS

eight patients receiving endovascular stent grafts (STENT) and six patients undergoing open aortic surgery (OPEN) for abdominal aortic aneurysms were studied prospectively but non-randomised.

METHOD

microdialysis catheters placed subcutaneously in the pectoral and calf region, respectively.

RESULTS

microdialysate glucose levels increased in the OPEN group on the day of surgery. Microdialysate lactate levels increased transiently in the leg in the STENT group. In the OPEN group lactate increased in the leg after aortic cross-clamping. Glycerol decreased in the pectoral region in the STENT group after surgery, but remained elevated in the OPEN group.

CONCLUSION

we found indications that the metabolic impact of the two aortic procedures differ. This may be of clinical importance when selecting patients for either open aortic surgery or endovascular stentgrafting.

Response of inflammatory markers to balloon angioplasty in peripheral arterial occlusive disease

OBJECTIVES

To study the inflammatory response to balloon angioplasty (PTA).

DESIGN

Prospective study.

MATERIALS

Blood samples were drawn for cytokine analysis from 10 patients undergoing PTA before, after 60 min and 6 h after the balloon inflation. Adhesion molecules were analysed in 14 patients undergoing PTA and in seven patients undergoing angiography only. Arterial samples were taken in eight patients, before PTA, immediately after and 15 min later. Venous samples were taken in six patients and in the group undergoing angiography only. The sampling was before, 60, 90 and 120 min after the procedure. As controls served 15 patients with no signs of peripheral arterial disease.

METHODS

Cytokines (IL-6, TNF-alpha) were analysed using ELISA. Adhesion molecule expression on WBC was measured by flow cytometry.

RESULTS

A significant increase of IL-6 in the sample taken 6 h after the last balloon inflation was seen in five patients. TNF-alpha was raised only in one patient. The group of patients with peripheral arterial occlusive disease (PAOD) expressed pre-interventionally a higher level of adhesion molecules on WBC compared to the controls. The expression of adhesion molecules (CD11b/CD18) was significantly decreased after PTA.

CONCLUSION

Only a very limited cytokine response is caused by PTA reflecting the small surgical trauma. PTA results in a downregulation of detectable CD11b/CD18 expression on WBC in the circulation, which may reflect removal of activated cells through adhesion and extravasation.

[Varices and venous insufficiency--therapeutic philosophy prior the 2000's]

Varicose veins represent everything from a cosmetic problem to a risk of venous leg ulcers. Predicting the risk of complications has been difficult, not least due to less than satisfactory diagnostic procedures. Recent investigations have pointed out some important new concepts: Superficial venous incompetence may give rise to an ulcer, and such an ulcer may be prevented by varicose vein surgery. Recanalization and stenting may be useful in treating chronic iliac and caval venous occlusions; however, long-term outcome is yet to be established. Venous diameter can be reduced, thus effecting valve competence. To what extent this result is long-lasting is not known. Neither has the method been attempted on deep veins. Clinical diagnosis is never sufficient in cases of suspected chronic venous incompetence. The minimum requirement is the use of a hand-held Doppler. Frequently, a more detailed ultrasonographic analysis is required, and for a global assessment of venous function, plethysmographic techniques are useful. Primary health care may contribute effectively to the care of venous leg ulcers.

[Vascular surgery after the year of 2000--challenges for the future]

Vascular surgery is in a dynamic phase of rapid development. Particularly endovascular procedures have revolutionized the care of vascular patients. Around 35-40% of all interventions in Sweden are endovascular. In all aspects of vascular surgery (arterial, venous, endovascular, biomaterials) there is a great need for more basic knowledge. The organization of vascular units must be centered around the vascular patient. Specialists need to collaborate in the care of each patient. It is proposed that the care of vascular patients should be organized in Vascular Departments.