Multiple microemboli after disintegration of clot during thrombolysis for acute myocardial infarction

Seven of 475 consecutive patients treated with thrombolysis for acute myocardial infarction had severe embolic complications that were believed to be caused by disintegration of pre-existing clot. Three patients had symptoms that persisted for many weeks, and five died. Any potential site of pre-existing blood clot within the vascular system, notably an enlarged left atrium, ventricular aneurysm, or aortic aneurysms, should be regarded as a contraindication to treatment with thrombolytic agents.

Lack of correlation between intracavitary thrombosis detected by cross sectional echocardiography and systemic emboli in patients with dilated cardiomyopathy

The correlation between intracavitary thrombosis detected by cross sectional echocardiography and systemic embolism was studied in 126 consecutive patients with idiopathic dilated cardiomyopathy who were examined from January 1980 to September 1987. A total of 1041 serial echocardiograms were obtained with 3.5 and 5 MHz transducers. The mean follow up period was 41.2 months. The survival rate was 88% at two years and 56% at five years. Echocardiography showed intracavitary thrombi in 14 (11.1%) patients; 13 were mural and 11 were localised at the apex of the left ventricle. Twelve patients (8.4%) had systemic emboli; this corresponded to an incidence of new embolic events of 1.4 for 100 patient-years. Patients with intracavitary thrombi or systemic emboli were treated with oral anticoagulants, as were nine in functional class IV of the New York Heart Association, for 61 patient-years. The cumulative observation period for the whole population study was 418 patient-years. None of the patients with intracavitary thrombosis had embolic complications and none of those with embolism had intracavitary thrombi. Rates of intracavitary thrombosis and systemic embolism in this series were low and there was no overlap between the two events. This may have been because the patients did not have severe dilated cardiomyopathy, because echocardiography did not detect all the thrombi, or because patients were treated with oral anticoagulants. The presence of intracardiac thrombosis detected by cross sectional echocardiography is not predictive of systemic embolism in patients with idiopathic dilated cardiomyopathy. Criteria for the use of the anticoagulant treatment remain largely empirical in these cases.

[Local thrombolysis in peripheral arterial occlusion]

Peripheral arterial occlusions, with the exception of those induced mechanically or by vasospasm, are invariably caused by a blood clot resulting from either in-situ thrombosis or embolism. More than 10% of embolic occlusions in otherwise healthy arteries undergo spontaneous lysis due to the organisms tissue plasminogen activator. In thrombotic occlusion of arteriosclerotic vessels, probably due to insufficient activator release from the diseased arterial wall, spontaneous lysis is much less common. For more than 25 years, lysis has been aided with streptokinase (SK) or urokinase (UK) which, until eight years ago, had only been given systemically with a standard dosage of 2.4 million units daily for up to five days. Thrombotic femoral artery occlusions of up to six weeks old were successfully lysed in 48%, six to twelve weeks old in 25% and, in those older than twelve weeks only in exceptional cases. With embolic occlusion, systemic lysis is contraindicated due to the possibility of provoking new emboli. With conventional systemic SK treatment, in 7% of the patients there was severe bleeding which in 1.12% was fatal. The ultrahigh SK treatment (nine million units in six hours) has substantially fewer bleeding complications but no better rate of success. Systemic administration of SK and UK leads to activation of the entire circulating plasminogen and the correspondingly-associated clotting defects. Recombinant tissue plasminogen activator (rt-PA), the production of which was rendered possible by genetic engineering, is identical to human tissue activator, has a high affinity to fibrin-bound plasminogen, less affinity to circulating plasminogen. After systemic administration, however, the plasminogen in every vascular clot is activated such that, even without alteration of the clotting system, bleeding the emboli can be provoked. With local application of the activator, even extensive clots, provided they contain lysable fibrin, can be dissolved within one-half to three hours with comparably minimal doses. For local lysis treatment of peripheral arterial occlusions, SK, UK and rt-PA are well-suited. With a total dose of maximally 30,000 units SK, in contrast to the initially-used higher doses, there were no bleeding complications in more than 300 patients. Even with a total doses of 100,000 to 300,000 UK, albeit in a relatively small number of patients, and a total dose of 2.5 to 7.5 mg rt-PA which was given within three hours maximally to 85 patients, there were no bleeding complications.(ABSTRACT TRUNCATED AT 400 WORDS)

Normalization of renal function and blood pressure after dissolution with intra-arterial fibrinolytics of a massive renal artery embolism to a solitary functioning kidney

The intra-arterial administration of fibrinolytics in a massive embolism to the renal artery of a solitary functioning kidney determined quick normalization of the severe renal failure and hypertension.

Beneficial effects of intra-arterial reserpine after upper-extremity embolectomy: a prospective randomised trial

Persistent ischaemia occasionally follows technically-successful arterial embolectomy, and has generally been ascribed to small-vessel thrombosis in the distal vascular bed. Because of the possibility that distal vasospasm might be a contributory cause, we conducted a prospective randomised trial of vasodilator therapy in this setting. In 50 consecutive patients presenting with their first episode of upper-extremity arterial embolism, we compared the results of the intra-arterial instillation of 0.5 mg reserpine with those of saline alone following embolectomy. Among 29 patients receiving saline only, 13 (44.8%) suffered persistent or recurrent limb ischaemia requiring reoperation, while three (14.3%) of 21 patients receiving reserpine had continuing ischaemia (P = 0.02). Three patients in each group required a second re-operation; all three in the reserpine group were ultimately found to have a proximal axillo-subclavian artery stenosis as the cause for their persistent or recurrent limb ischaemia. Although its underlying pathophysiology remains obscure, peripheral vasospasm appears to accompany acute embolic arterial occlusion. Manoeuvres to prevent or reverse such distal vasoconstriction may be useful in avoiding persistent or recurrent ischaemia following arterial embolectomy.

Embolization of cardiac mural thrombus: complication of intraarterial fibrinolysis

A case of embolization of cardiac mural thrombus during intraarterial infusion of urokinase is reported. The mechanism of embolization is believed to be secondary to a systemic fibrinolytic effect induced by urokinase.

[Diagnostic and therapeutic role of angiography in acute vascular insufficiency of the superior mesenteric artery]

Sixteen patients were studied with acute arterial ischemia of the superior mesenteric artery: 2 thrombosis, 8 embolisms, and 6 non-occlusive ischemias. Six patients had intra-arterial selective perfusion of papaverine. Angiographic patterns of acute arterial ischemia of the superior mesenteric artery are described. The technique of intra-arterial injection of papaverine (fast bolus followed, if needed, by slow perfusion) is also described. The diagnostic value of plain abdominal radiography and arteriography, and the therapeutical value of pharmacoangiography are discussed.

Benign disappearance of ventricular thrombus after embolic stroke. A case report

The source for a patient's middle cerebral artery territory embolic stroke was found by echocardiography to be a left ventricular cardiac thrombus. The apical mass was large, pedunculated, and moved with systole into the ventricular cavity. The absence of ventricular dyskinesia was thought to favor a tumor, and surgery was considered before repeat echocardiography showed disappearance of the mass, making thrombus the likely diagnosis. No further embolic events occurred during or since the disappearance of the thrombus while on anticoagulation therapy. Serial echocardiography for change in or disappearance of a ventricular mass may be critical in distinguishing thrombus from tumor.

[A case of renal artery embolism treated with urokinase]

Herein we describe a 59-year-old man with left renal artery emboli treated with selective intra-arterial infusion followed by systemic intravenous infusion of urokinase. Total dose of infused urokinase was 2,712,000 units. Although the function of the affected kidney was not recovered, we have demonstrated successful clot lysis and no complication. Selective or systemic thrombolytic therapy is extremely promising as a method of treatment of renal artery embolism, especially in the poor operative candidate. The availability of this potentially efficacious therapy suggests that aggressive diagnostic studies be performed early in patients suspected of having renal artery embolism.

Left ventricular thromboembolic occlusion of the popliteal artery treated nonoperatively with local urokinase infusion--a case report

Recently streptokinase and urokinase have been shown to be useful in the nonoperative treatment of thromboembolic disease. Urokinase is emerging as a safer and more effective thrombolytic agent when applied either to definitively lyse spontaneous thrombosis where no underlying structural lesion is present or to serve as an adjunct prior to surgical reconstruction or transluminal angioplasty. The authors report a case of a high-risk cardiac patient in whom an embolic occlusion of the distal popliteal artery was completely recanalized by using a localized catheter infusion of urokinase. The source of the embolus was a left ventricular thrombus. No serious bleeding or proximal or distal embolic complications occurred. The potential hazards of fragmentation of the embolic source in the presence of systemic thrombolysis, distal trifurcation embolization, and concomitant use of heparin are reviewed.

Blue toe syndrome: treatment with anticoagulants and delayed percutaneous transluminal angioplasty

The spontaneous onset of a painful unilateral blue toe is usually caused by fibrinoplatelet microemboli arising from an upstream stenotic or occlusive lesion of the iliac or femoral artery. This constellation of findings is referred to as the blue toe syndrome (BTS). In 12 patients who experienced 14 spontaneous episodes of BTS, angiography demonstrated 15 proximal atherosclerotic arterial lesions, which were presumed to be the source of the microemboli. Fourteen of the 15 lesions were short-segment stenoses or occlusions distal to the aortic bifurcation. Six lesions were treated with antiplatelet or anticoagulant drugs followed by delayed percutaneous transluminal angioplasty (PTA) 6-12 weeks later. Three lesions were treated with surgical bypass, three with long-term anticoagulation, and one with transcatheter clot aspiration and immediate PTA. Two were treated with immediate thrombolytic therapy and had embolic complications. Antiplatelet and anticoagulant therapy followed by delayed PTA may be an effective alternative to surgery for treating BTS.

A flexible loading dose schedule for warfarin therapy

A flexible loading dose schedule for inducing anticoagulation with warfarin was assessed in 31 consecutive patients. 55% reached the therapeutic range (prothrombin ratio between 2 and 4:1) by Day 2 (40 hours after the first dose) and this figure rose to 77% on Day 3 and to 87% on Day 4. All patients had a PTR between 1.7 and 4.2 on Day 5. Patients with evidence of cardiac failure and abnormal liver function, and those taking medications known to interact with warfarin required lower doses and ran a higher PTR when compared with the total group of patients. This schedule offers a useful means of safely and rapidly inducing warfarin therapy in all patients.

Arterial and venous embolization: declotting of dialysis shunts by direct injection of streptokinase

During the past 33 months, thrombolysis of 79 clotted hemodialysis shunts was attempted by injecting small quantities of dilute streptokinase solution directly into the clotted shunt, followed by massage of the clot. Embolization of clot fragments in six of 79 cases (7.6%) was demonstrated angiographically. In four of the six cases embolization involved the brachial artery or its branches. In one case embolization involved an arm vein, and in one case embolization involved both the brachial artery and axillary vein. All patients remained asymptomatic, and repeat angiographic study, usually performed the following day, showed resolution of the emboli in four of five cases. The incidence of embolization in direct-injection thrombolysis reported in this study appears to be comparable to that reported in studies using the streptokinase infusion technique.

Ulnar artery aneurysm complicated by distal embolization: management with regional thrombolysis and resection

We report the first use of preoperative regional thrombolysis followed by resection and primary anastomosis performed for distal embolization that complicated ulnar artery aneurysm. This treatment scheme may be applicable to other situations in which distal emboli complicate the management of arterial lesions.

Arterial embolism and fibrinolysis. A case report

Medicinal lysis with an intra-arterial streptokinase infusion was used in a patient who had suffered multiple embolic occlusions 2 weeks after a myocardial infarction. The good outcome, as verified by arteriography, and the experience of other groups, makes it clear that there is a specific place for this therapy in such patients. Concomitant arterial stenosis should be treated by transluminal angioplasty to prevent re-thrombosis.

[Treatment of acute thromboses and embolisms of the arteries of the extremities in cardiosclerosis patients]

An experience with the surgical and conservative treatment of 196 patients with acute thromboses and embolism of the extremity arteries in patients with arteriosclerotic and postinfarction cardiosclerosis has shown the conservative treatment of arterial embolism to have little effect. Results of the surgical treatment were regularly better in patients admitted to the hospital at earlier terms after acute occlusion of the vessel, with mild ischemia and the absence of a considerable atherosclerotic lesion of the extremity interrupting the major blood flow. For prophylactics of a repeated embolism of considerable significance were found to be correcting operations on the heart and the continuous anticoagulating therapy.

[Cerebral embolism of cardiac origin: when to anticoagulate?]

In order to decide if i.v. anticoagulation with heparin is indicated in patients with a cerebral infarct from cardiac embolism, the risks of anticoagulant-induced bleeding into the ischemic area must be compared with the risks of embolic recurrence without anticoagulant therapy. Although methodologically imperfect, some studies have reported findings which may help to decide whether to anticoagulate or not. Some risk factors for intracerebral hematoma within the infarct, the most severe complication of anticoagulation, can be identified. The potential benefits also depend upon our ability to establish that a cerebral infarct is in fact due to an embolism from the heart, which is not always possible in the present state of knowledge.