Evaluation of cases with combined bronchoplasty and pulmonary arterioplasty for the treatment of lung cancer

Bronchoplasty and pulmonary angioplasty(PA-plasty) have been performed in recent years for lung cancer invading the bronchus and pulmonary artery. We evaluated the results and complications in patients who underwent such operations. There were 23 cases of bronchoplasty performed between 1988 and October 1993. Of these 23 cases, 9 underwent PA-plasty with bronchoplasty. There were 8 males and 1 female (mean 65.6 year-old). There were 8 patients with primary lung cancer(sq 5, ad 1, la 1, and sm 1) and 1 with metastatic lung tumor of colon cancer. One patient was in p-stage II, 6 in p-stage III, and 1 in p-stage IV. Seven patients underwent right upper lobectomy, 1 did the right upper and middle bilobectomy, and 1 did a left upper lobectomy. Bronchoplasty was performed using sleeve resection in 8 patients, and a wedge resection in 1 patient. PA-plasty was performed using sleeve resection and end to end anastomosis in 2 cases, and using side wall resection and plasty in 7 patients after clamp. Of 9 patients in whom both broncho- and PA-plasty were performed, there was one with the resected bronchial stump of cancer-positive. Total resection of the cancer was possible in the remaining 8 patients. Postoperative complications included 2 pneumonia, 2 empyema, and 1 each, acute cardiac failure, pulmonary thrombus, and chylothorax. The patients with empyema required re-operation using omentopexy or thoracoplasty. Long-term results showed that 2 patients died because of recurrence. Another patient died of respiratory failure. The remaining 6 patients were alive without any evidence of cancer. Pneumonectomy was avoided and the combination of PA-plasty and bronchoplasty was performed instead. However, the incidence of postoperative complications was high, indicating that utmost care must be exercised in the postoperative management of these patients.

Stabile D-peptide analog of insulin-like growth factor-1 inhibits smooth muscle cell proliferation after carotid ballooning injury in the rat

Restenosis after angioplasty is believed to result from stimulation of smooth muscle cells (SMC) by various growth-promoting factors as a consequence of endothelial injury. In this study we have tested the hypothesis that insulin-like growth factor-1 (IGF-1)/IGF-1 receptor (IGF-1R) interaction is a rate-limiting step for SMC replication by blocking this interaction with a synthetic D-amino acid peptide structurally resembling the D-domain of IGF-1. After rat carotid artery denudation, semiquantitative PCR analysis demonstrated a significant elevation of IGF-1, platelet-derived growth factor B, transforming growth factor beta 1, and epidermal growth factor mRNAs 10 days after endothelial injury, concomitantly with the induction of intimal SMC proliferation and intimal thickening. Administration of 10-30 micrograms.kg-1.day-1 of D-analog of IGF-1, devoid of proteolytic degradation in body fluids, reduced intimal SMC replication by 60-70%. The peptide also inhibited [3H]TdR incorporation and [3H]glycine incorporation in cultured SMCs by 60-80%, whereas a "scrambled" control peptide consisting of the same amino acids had no effect. The results suggest that IGF-1/IGF-1R interaction is a rate-limiting step for SMC replication. Blocking of this interaction with stabile D-peptide analog of IGF-1 at the level of IGF-1R may offer an entirely new approach for the prophylaxis and treatment of restenosis after cardiac revascularization procedures.

Improved outcome after rupture of anterior circulation aneurysms: a retrospective 10-year review of 224 good-grade patients

Several significant diagnostic and therapeutic advances in the management of subarachnoid hemorrhage have emerged during the last 10 years. The present study was undertaken to determine whether these advances have improved overall outcome in patients of low surgical risk and what factors predict outcome. The authors retrospectively reviewed the management of good-grade patients seen at the Harborview Medical Center at the University of Washington, who suffered ruptured anterior circulation aneurysms between 1983 and 1993. The results in this series demonstrate that favorable outcomes occurred in 96.8% of patients designated Hunt and Hess Grade I, 88.3% of those assigned Grade II, and 81.3% of those deemed Grade III after rupture of anterior circulation aneurysms. On the basis of clinical and radiographic factors present at admission, correct prediction can be made about all favorable, but only 17% of unfavorable outcomes. During the decade under investigation, the authors observed a significant (p = 0.002) increase in the number of favorable outcomes: 74.5% of patients treated during the first management period (1983-1987); 87% of patients treated during the second period (1987-1990); and 93.5% of patients treated during the third management period (1990-1993) experienced favorable outcomes. Improvements in critical-care techniques and the management of vasospasm may be associated with the improved outcome observed during this series.

The FemoStop compression device: utilization guidelines for the critical care nurse

FemoStop is an exciting new femoral compression device being used on patients by critical care nurses. It is now common practice in many settings for the nurse to remove post-angioplasty and post-cardiac catheterization sheaths. In settings where physicians are primarily removing these devices, nurses must then be prepared to deal with site bleeding, post-sheath removal. FemoStop provides a means to do this. An understanding of the utilization guidelines for this product is beneficial and timesaving for busy nurses in many settings.

How much now to tell? Patients' attitudes to an information sheet prior to angiography and angioplasty

A prospectively controlled pilot study of 100 patients undergoing an invasive radiological procedure was undertaken to test patients' acceptance of risk disclosure and whether this increases anxiety and rate of procedure cancellation. Two sheets with differing amounts of information on adverse outcome were randomly allocated and patients provided a graded response to statements following the procedure. Eighty-one completed questionnaires were received (brief sheet n = 40; long sheet n = 41). There were 19 non-compliers with main causes either due to lack of interest or problems such as language difficulties, visual impairment and dementia. There were no significant differences between the two groups with respect to subjective anxiety caused by the information or risk of procedure cancellation. This preliminary work has shown that information sheets are well accepted and provide a simple, standardized format for risk disclosure.

Predictors of groin complications after balloon and new-device coronary intervention

We reviewed the clinical course of 5,042 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) using balloons or new devices: (stent, laser, directional and rotational atherectomy). A vascular complication was defined as the formation of a groin hematoma, bleeding, pseudoaneurysm, fistula, or the need for surgical repair. Vascular complications occurred in 309 (6.1%) patients, and 117 (2.3%) required vascular repair; among these patients, surgery was performed for correction of an an arteriovenous fistula in 12%, repair of pseudoaneurysm in 72%, repair for expanding hematoma and femoral artery lacerations in 10%, and retroperitoneal bleeding in 6%. The correlates of vascular complications were older age (66.8 vs 62.1 years; p < 0.0001), female gender (43% vs 26%; p < 0.0001), increased weight (82.1 +/- 16.46 vs 78.0 +/- 16.6 kg; p < 0.001), higher systolic blood pressure (140 +/- 25 vs 134 +/- 20 mm Hg; p < 0.001), increased heparin dose during the procedure (14,352 +/- 3,879 vs 13,599 +/- 3,508 IU; p = 0.001), administration of heparin after the procedure (232 vs 2,985 patients; p < 0.0001) and intracoronary stenting (14.9% vs 3.5%; p < 0.0001). Fifteen patients of 214 (7.0%) who underwent stent implantation had surgical repair. Vascular complications were not related to the size of the arterial sheath (8.11 +/- 0.8 vs 8.8 +/- 0.7Fr; p = 0.11) and the use of devices other than stents (laser, atherectomy) did not increase the rate of vascular complications.

Different localization of ETA and ETB receptors in the hyperplastic vascular wall

We investigated which subtypes of endothelin-1 (ET-1) receptors are involved in the pathogenesis of angioplasty-induced lesion formation in the rabbit carotid artery. Four weeks after removing endothelial cells (EC), we noted a marked intimal hyperplasia. The Bmax values for [125I]ET-1 and [125I]IRL1620 (an agonist for the ETB receptors) bindings were greater in the hyperplastic artery, without changes in Kd values. [125I]ET-1 binding was completely inhibited by unlabeled ET-1 and Ro 46-2005, a mixed-type antagonist for the ETA and ETB receptors, but partially by BQ123, a selective antagonist for ETA receptors, and IRL1620. The [125I]ET-1 binding sites not inhibited with BQ123 were significantly increased in the hyperplastic artery. The binding study suggested the presence of non-ETA/non-ETB receptors. The rank order of the increasing ratio in the density of receptors was ETB > putative non-ETA/non-ETB > total ET-1 receptors > ETA. The histochemical experiments with biotinylated ET-1 at lysine-9 side chain alone or in combination with unlabeled ET-1, BQ123, Ro 46-2005, or IRL1620, showed the ETA receptors to be localized mainly in the media, whereas the ETB receptors localized mainly in the neointima. These results suggest that the increased ET-1 receptors, especially ETB and/or putative non-ETA/non-ETB, are closely related to the occurrence of the intimal hyperplasia after endothelial removal.

[Effect of antisense oligonucleotides on myo-intimal hyperplasia in a model of abdominal aortic injury in the rat]

Restenosis at a rate > 30% at 6 months is the major complication of both coronary and peripheral arterial angioplasty. Restenosis is mainly due to proliferation of smooth muscle cells, extracellular matrix and collagen which form a neointima. The proto-oncogene c-myb is a gene with an immediate response which has been implicated in the proliferation and alteration of the phenotype of smooth muscle cells. The antisenses are molecules of single-helix DNA the sequence of which is inverse to that of messenger RNA of the target proto-oncogene. They therefore have the possibility of forming a double helix with the messenger RNA and of preventing its translation. The antisenses of c-myb have already been successfully tested in in vitro and in vivo models of neointimal proliferation. The aim of this study was to demonstrate the efficacy of c-myb antisenses on the proliferation of smooth muscle cells in a model of abdominal aortic injury in the rat. Thirty-five male Wistar rats with an average weight of 350 grams were operated. Smooth muscle cell proliferation was obtained by desendothelialisation of the abdominal aorta from the level of the left renal vein to the aortic bifurcation. Using a randomised, double-blind protocol, 17 rats were given 500 microliters of pluronic gel (control group), 9 a sense oligonucleotide of c-myb in 500 microliters of pluronic gel (sense group) and 9 a c-myb antisense oligonucleide in 500 microliters of pluronic gel (antisense group). Two rats were given fluorescinlabelled antisenses; one was sacrificed 4 hours and the other 24 hours later.(ABSTRACT TRUNCATED AT 250 WORDS)

Early outcome and intermediate follow-up of vascular stents in the femoral and popliteal arteries without long-term anticoagulation

PURPOSE

The role of arterial stenting in the treatment of femoral and popliteal arterial disease is controversial and has been hampered by recommendations for patients to be given anticoagulants (oral warfarin) for several months or more. This study was undertaken to evaluate the immediate and midterm outcomes of vascular stents implanted percutaneously in the femoral and popliteal arteries, without long-term anticoagulation.

METHODS

Over a 3-year period, 32 patients admitted to a vascular surgery service had arterial stents implanted in the femoral (n = 22) or popliteal (n = 10) artery for the following indications: recurrent stenosis after angioplasty (n = 13), suboptimal result after angioplasty of occluded (n = 12) or calcified stenotic arteries (n = 2), percutaneous transluminal angioplasty-induced thrombosis or dissection (n = 5). Access to the artery was gained by percutaneous insertion of a hemostatic sheath into the ipsilateral common femoral artery. Systemic heparin was given at the time of stent insertion, and patients were prescribed daily low-dose aspirin.

RESULTS

Successful stent implantation was achieved in 31 of the 32 patients. Acute thrombosis (< 30 days) occurred in two patients. There was no incidence of false aneurysm formation, acute leg ischemia, or vessel perforation. All patients were monitored by Doppler scanning index and duplex scanning within 24 hours, and thereafter at 3- to 6-month intervals. The mean ankle-brachial systolic pressure index improved from 0.60 (before treatment) to 0.88 (3 to 6 months after stenting). Stent occlusion has occurred in six patients; two stents were successfully salvaged with urokinase infusion. In follow-up to date (range 3 to 33 months) the primary patency rate by life-table analysis was 75% at 18 months, whereas the secondary patency rate was 89% at the same interval. Restenosis (> 50% lumen diameter) was detected by duplex ultrasonography in seven of 25 patent stents (28%) at a mean interval of 9.5 months (range 4 to 15 months); of these, four patients remained clinically symptom-free despite the ultrasound findings.

CONCLUSIONS

We conclude that vascular stents can be implanted into the femoropopliteal arteries with few complications and with acceptable early and intermediate patency rates, without the need for long-term anticoagulation. Restenosis is not prevented by stents, and the main value of stenting at this site appears to be in salvaging acute complications of percutaneous transluminal angioplasty, or to correct suboptimal results after recanalization of occluded arteries.

Systemic interleukin-1 alpha and interleukin-2 secretion in response to acute stress and to corticotropin-releasing hormone in humans

Acute stress results in activation of the hypothalamic-pituitary-adrenal (HPA) axis. ACTH and cortisol secretion is stimulated by corticotropin-releasing hormone (CRH). It has also been shown that activation of the HPA axis during stress is accompanied by changes in the immune response. However, little is known about the influence of acute stress on the release of cytokines such as interleukin-1 (IL-1) or interleukin-2 (IL-2). In this study, we determined serum IL-1 alpha and IL-2 levels in 19 patients undergoing the acute stress of angioplasty for coronary artery disease. A second protocol was devised to determine serum IL-1 alpha and IL-2 concentrations as well as lymphocyte subpopulations in 10 normal volunteers receiving 1 microgram kg-1 human CRH intravenously. Finally, IL-1 alpha concentrations were measured in CRH-incubated mononuclear cell (MNC) and monocyte cultures. In response to the stress of angioplasty, ACTH and cortisol as well as IL-1 alpha and IL-2 concentrations were clearly above baseline levels (IL-1 alpha, mean +/- SEM, baseline: 1.39 +/- 0.34 ng ml-1, after angioplasty: 2.64 +/- 0.73 ng ml-1, P < 0.05; IL-2, baseline: 1.2 +/- 0.13 ng ml-1, after angioplasty: 2.8 +/- 1.14 ng ml, P < 0.05). A similar pattern was obtained in normal subjects in response to CRH (Il-1 alpha, baseline: 0.8 +/- 0.2 ng ml-1, after angioplasty: 3.7 +/- 1.4 ng ml-1, P < 0.05; IL-2, baseline: 1.9 +/- 0.4 ng ml-1, after angioplasty: 5.4 +/- 2.2 ng ml-1, P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of endarterectomy combined with angioplasty in aortocoronary bypass]

From January 1989 until April 1990, 472 consecutive patients were operated for coronary artery bypass grafting. The patients were classified into three different groups. In group I, 412 patients were operated without endarterectomy. Group II consisted of 37 cases operated with endarterectomy-bypass to 41 vessels. Group III consisted of 23 cases of endarterectomy combined with patch-plastybypass to 24 vessels. The length of the segment endarterectomized was 25 to 70 mm (mean 37.86 +/- 12.18 mm). Peri-operative myocardial infarction occurred in 19 cases in group I (4.61%), 6 cases in group II (16.21%), and 3 cases in group III (13.04%). The percentage of IABP utilization was 2.91% in group I; 10.81% in group II; 8.69% in group III. The hospital mortality for group I, group II and group III was 3.88%; 8.10% and 8.69%. Mean follow-up was 16.4 months for 72% of patients. In 5 cases of group I (1.80%), in 8 cases of group II (27.58%) and in one case of group III (5.55%), myocardial infarction occurred in the late post-operative period. Late mortality was 1.44% for group I; 17.24% for group II and 5.55% for group III. There was no statistically significant difference between groups II and III, but the late results of group III are probably better.

Percutaneous aspiration thromboembolectomy to manage the embolic complications of angioplasty and as an adjunct to thrombolysis

Percutaneous aspiration thromboembolectomy (PAT) can be used to treat the embolic complications of angioplasty. The same technique is of value during thrombolysis to remove large pieces of thrombus. We report on our experience with PAT in 21 patients. Fourteen of these patients had embolization complicating peripheral angioplasty and in one case embolus complicated directional atherectomy. PAT was successful in 87% of these patients (13/15). In six patients undergoing thrombolysis of acute peripheral occlusions, all had successful PAT to shorten their treatment episode immediately prior to angioplasty of any underlying stenosis. PAT can be performed with a simple, inexpensive catheter under fluoroscopic control and therefore offers significant advantages over a surgical embolectomy using the Fogarty balloon catheter. PAT is a useful treatment option for the vascular radiologist.

Perforations after percutaneous coronary interventions: clinical, angiographic, and therapeutic observations

Coronary perforation is a rare, but potentially catastrophic, complication of percutaneous coronary intervention. A retrospective review of the Cardiology Quality Assurance Database was performed for all percutaneous coronary interventions (n = 8,932) at William Beaumont Hospital from October 1988 to December 1992. Coronary artery perforation was reported in 35 patients (0.4%), including after percutaneous transluminal coronary angioplasty (PTCA, 11/7,905, 0.14%), transluminal extraction coronary atherectomy (TEC, 6/420, 1.3%), directional coronary atherectomy (DCA, 1/249, 0.25%), and excimer laser coronary angioplasty (ELCA, 5/242, 2%); and none after high-speed mechanical rotational atherectomy with the Rotablator (MRA, 0/116, 0%). Perforations were classified by coronary angiography as free perforations (n = 10), contained perforations (n = 17), or other types of perforation (n = 8). Although perforation was apparent in 32 (91%) of 35 angiograms, delayed cardiac tamponade occurred in 3 patients (9%), despite the absence of angiographic evidence for perforation at the time of the procedure. Causes of perforation were the guidewire in 7 (20%), an interventional device in 26 (74%), and indeterminate in 2 (6%). Complex B2 or C lesions accounted for 83% of perforations. Final treatment included conservative therapy (reversal of anticoagulation and/or PTCA) in 22 (63%) and surgical intervention (with or without bypass surgery) in 13 (37%). Serious clinical complications included cardiac tamponade in 6 (17%), blood transfusion in 12 (34%), myocardial infarction in 9 (26%), and death in 3 (9%).

Scintigraphic localization of the bleeding site of a large retroperitoneal hematoma following renal angioplasty

Although the scintigraphic detection of a few soft tissue hematomas have been reported, these usually have been serendipitous discoveries that were small and self-limited. The authors report a case of a large, rapidly expanding retroperitoneal hematoma that occurred following a left renal angioplasty. While the hematoma was initially detected by CT imaging, the precise source of the bleeding could not be definitively localized. Scintigraphy with labeled RBC cells, however, identified the left femoral artery puncture site as the bleeding source, which was subsequently surgically repaired.

Electrophysiologic basis for T wave alternans as an index of vulnerability to ventricular fibrillation

Substantial evidence indicates that T wave alternans is an intrinsic property of ischemic myocardium. The electrophysiologic basis appears to be spatial and temporal heterogeneity of repolarization resulting from changes in action potential morphology rather than in activation sequence. Ischemia-induced changes in postrepolarization refractoriness and depressed electrical restitution of action potential duration have also been implicated. The main underlying ionic basis for T wave alternans during coronary occlusion appears to be derangements in intracellular cycling of calcium. Accumulation of potassium in the extracellular space adjoining ischemic cells and disruption in electrogenic sodium-calcium exchange may also be involved. In humans, T wave alternans has been observed in Prinzmetal's and classical angina, angioplasty, and bypass graft occlusion. Under these conditions associated with acute myocardial ischemia, alternans is restricted to the ischemic zone, and alternation in action potential morphology is an underlying factor. Recently, repolarization alternans has been shown to be a statistically significant predictor of the results of electrophysiologic testing and arrhythmia-free survival in individuals with and without organic heart disease. Collectively, these observations provide a rationale for quantitation of T wave alternans magnitude for assessment of vulnerability to life-threatening ventricular arrhythmias both in response to and independent of the effects of myocardial ischemia.

[Preventive percutaneous radiotherapy for avoiding hyperplasia of the intima following angioplasty together with stent implantation]

PURPOSE AND BACKGROUND

Interventional radiologic procedures play an important role in the management of peripheral arterial occlusive disease. Percutaneous transluminal interventions as angioplasty (PTA) and implantations of metal-stents injure the wall of the blood vessels resulting in hyperplasia of the intima and media. In spite of adequate anticoagulation therapy restenosis and reocclusion frequently occur. Our study was designed to prevent hyperplasia of the intima by percutaneous radiation therapy.

PATIENTS AND METHODS

A total of 24 patients had a stent implanted in their superficial femoral artery from 1990 to 1992. Eleven patients received percutaneous radiation therapy of the enlarged stent area on five consecutive days with a single dose of 2.5 Gy thus resulting in a total dose of 12.5 Gy. Both patients groups were compared. None of the patients in the radiation group suffered from complications.

RESULTS

In the seven months following stent implantation and radiation only two of eleven patients in the radiation group suffered from occlusion of the stent that had to be treated by vascular surgery. In comparison five of 13 patients treated with stent implantation alone suffered from occlusion of the stent within the first eight to nine months.

CONCLUSION

In spite of a small case number our study shows a positive influence of percutaneous radiation therapy on the extent of hyperplasia of the intima after stent implantation leading to lower reocclusion rates. Whether these results can be improved by alternative dose-fractionation schedules has to be addressed by further studies.

Long-term results of a single protocol for thrombolysis in acute lower-limb ischaemia

In a prospective study, 78 of 157 patients with acute lower-limb ischaemia were considered suitable for thrombolysis. The immediate and 4-year results of 52 patients managed by a single protocol are reported. Of 34 patients alive at 4 years, 23 had limb salvage. Initial treatment produced effective lysis in 38 patients (73 per cent) with significant benefit in 35 (67 per cent); that benefit was sustained for a minimum of 4 years in 30 patients (58 per cent). Seven of the 18 deaths by 4 years occurred within 30 days. Amputation was carried out in six patients within 30 days and in five during the next 4 years. Delayed amputation followed persistent distal occlusion or progression of distal disease. No death or amputation was caused by complication of treatment. In selected patients the risks of thrombolysis can be reduced to an acceptable level by personal supervision and a strict protocol. In survivors, limb salvage is generally sustained for at least 4 years.