P3717More fresh thrombi in cardio embolic than vascular related acute vessel syndromes

Background

Acute thrombotic occlusion may lead to major life threatening syndromes such as ST elevation myocardial infarction (STEMI) or stroke. In the majority, the underlying pathophysiology may be related to local vascular factors or thrombotic emboli. Thrombus composition might be indicative of underlying etiology and affect therapeutic considerations. Comparison of thrombi of patients suffering from both these acute syndromes has not been made yet. In this study, we compared the “age” of thrombi of patients with STEMI and acute large vessel occlusion related stroke (LVOS).

Methods and results

A total of 126 consecutive patients underwent thrombectomy for either STEMI (n=51) or LVO (n=75). All STEMI patients had vascular related occlusions. Causes of LVOS were classified according to the TOAST criteria; i.e. large artery atherosclerosis (LAA), cardio embolic (CE), other determined and embolic stroke of unknown source. Aspirated material was histopathological ordered as fresh (<1 day old), lytic (1–5 days old) or organized (>5 days old). In general, thrombi of patients with LVOS were fresher compared to thrombi of STEMI patients (p=0,04). This difference is can be attributed mainly to CE patients, which had significantly younger thrombi (p=0.001). Thrombi of LAA had comparable age with thrombi of STEMI (Figure).

Conclusion

Thrombi of cardio embolic stroke are fresher compared to that of thrombi of atherosclerotic related stroke. The latter have thrombi with comparable age of that with thrombi of ST elevation myocardial infarction. These findings may have therapeutic implications in anti-thrombotic therapies.

QTL mapping of mycelial growth and aggressiveness to distinct hosts in Ceratocystis pathogens

Some species of Ceratocystis display strong host specificity, such as C. fimbriata sensu stricto that is restricted to sweet potato (Ipomoea batatas) as host. In contrast, the closely related C. manginecans, infects Acacia mangium and Mangifera indica but is not pathogenic to I. batatas. Despite the economic importance of these fungi, knowledge regarding the genetic factors that influence their pathogenicity and host specificity is limited. A recent inheritance study, based on an interspecific cross between C. fimbriata and C. manginecans and the resultant 70 F₁ progeny, confirmed that traits such as mycelial growth rate, spore production and aggressiveness on A. mangium and I. batatas are regulated by multiple genes. In the present study, a quantitative trait locus (QTL) analysis was performed to determine the genomic loci associated with these traits. All 70 progeny isolates were genotyped with SNP markers and a linkage map was constructed. The map contained 467 SNPs, distributed across nine linkage groups, with a total length of 1203 cm. Using the progeny genotypes and phenotypes, one QTL was identified on the linkage map for mycelial growth rate, one for aggressiveness to A. mangium and two for aggressiveness to I. batatas (P < 0.05). Two candidate genes, likely associated with mycelial growth rate, were identified in the QTL region. The three QTLs associated with aggressiveness to different hosts contained candidate genes involved in protein processing, detoxification and regions with effector genes and high transposable element density. The results provide a foundation for studies considering the function of genes regulating various quantitative traits in Ceratocystis.

Reinterventions following endovascular abdominal aortic aneurysm repair: the learning curve of time

AIM

The DREAM and EVAR-1 trial show a higher reintervention rate after endovascular aneurysm repair (EVAR) compared to open repair. Since the initiation of these trials, endovascular-graft design and the experiences with EVAR have evolved substantially. The aim of this study was to compare the need for reinterventions in our recent EVAR procedures with our early procedures.

METHODS

A retrospective review of our prospectively maintained database of all patients undergoing an elective EVAR for infrarenal abdominal aortic aneurysm (AAA) was performed. The 68 patients treated between 2000 and 2006 were defined as the "Early EVAR" group; the 41 patients treated between 2006 and 2008 were defined as the "Recent EVAR" group. The median follow-up was 63.3 (range 2-111) and 43.7 (range 1-61) months in the Early and Recent EVAR group respectively.

RESULTS

Treatment related mortality occurred in three (4.4%) patients in the Early EVAR group. No treatment related mortality occurred in the Recent EVAR group. In the Early EVAR group 16 reinterventions occurred in 13 patients (19.1%) and in the Recent EVAR group three reinterventions occurred in three patients (7.5%). This difference was statistically significant (P=0.039).

CONCLUSION

In our center, continued experiences with EVAR, improvement of graft design and a different management of complications have led to a significant decrease in reinterventions after EVAR. These findings and a review of the literature suggests that current need for reintervention after EVAR is substantially less than reported in the early trials.

Surgical removal of an infected aortic endoprosthesis using a wire cutter

The purpose of this study is to report a new method of removing an infected endoprosthesis from the abdominal aorta using a wire cutter. A 65-year-old man with a ruptured abdominal aortic aneurysm was admitted to our hospital. He was treated with an endovascular abdominal endoprosthesis and discharged one week later. Three months after placement, the patient returned with an infection of the aortic endoprosthesis. The endoprosthesis had been fixed with barbs and hooks above the renal arteries and was surgically explanted by using a wire cutter to cut the hooks. The bare suprarenal stent was left in place. The patient was discharged one month after stent removal, and was treated with oral antibiotics for another ten weeks. At one year follow-up the patient showed no clinical, biochemical, or radiological signs of infection. In conclusion, infected endoprostheses should be surgically removed according to the medical literature. We recognize that removing a Zenith endoprostheses requires a dangerous operation because the hooks of the bare stent are engaged into the supra-renal aorta. This case report documents a new technique to safely remove an infected endoprosthesis with the help of a wire cutter.

Endovascular aneurysm repair with Zenith graft. Complications caused by leg extensions

AIM

A large amount of Zenith endovascular stent complications is due to problems with the leg extensions. This kind of complication has never been reported in literature. The aim of this study was to monitor the complications of endovascular abdominal aneurysm repair (EVAR) performed with the Zenith endovascular graft occurred in the Amphia Ziekenhuis in Breda to see how many recurrences were due to leg extension.

METHODS

The study enrolled all patients (N.=66) treated with the Zenith endograft in the period between October 2000 and September 2006. Mortality, complications and the number of reinterventions were analysed. Average age of the patients was 73.4 years, average follow-up was 24.5 months and average aneurysm size was 61.5 mm. Radiologic follow-up was performed by computed tomography scans and X-rays.

RESULTS

Postoperative mortality rate was 0%. The overall mortality rate during follow-up was 3%. Ten patients required a total number of 12 reinterventions (15%). The average time for reintervention was 10 months after the primary operation. Mortality, complication and reintervention rates were comparable with those reported in the literature, but 75% of these reinterventions were related to the leg extensions.

CONCLUSION

Authors observed that nine out of 12 complications which required reintervention were due to problems with one of the leg extensions. This is the first study that specifies clearly the percentage of problems with leg extensions in EVAR (75%). When placing a Zenith endovascular graft extra attention should be paid to optimal placement of the leg extensions.

[Abdominal pain as a symptom of a late complication following endovascular treatment of an aneurysm of the abdominal aorta]

A 72-year-old man presented with progressive pain in the left lower abdomen thought to be due to diverticulitis of the colon. Antimicrobial therapy had not reduced the symptoms. Four years before, during an endovascular procedure, the patient had been given a stent because of an abdominal aortic aneurysm (AAA). A CT scan showed a large retroperitoneal haematoma on the left side and an increased diameter of the AAA of 8.5 cm. X-rays showed a gap between the endovascular stent and the left iliac leg of the endoprosthesis. Due to the space between the two grafts, there was retroperitoneal leakage ofblood. In endovascular surgery this life-threatening situation is called a type III endoleak. The patient was operated immediately using the endovascular technique. Through the left femoral artery a new coated stent was positioned over the gap, which led to rapid recovery of the patient. Patients with abdominal pain and a history of a vascular endoprosthesis should be given a CT scan and plain radiography to exclude an endoleak.

Mobility of people with lower limb amputations: scales and questionnaires: a review

OBJECTIVE AND DESIGN

A systematic literature review to compare mobility scales used for lower limb amputees. A literature search was carried out by computerized search of biomedical literature including Medline and Embase. The studies included were published between 1978 and 1998 and including the following keywords: amputation, artificial limbs, prosthesis, lower limb, activities of daily living, mobility.

RESULTS

Thirty-five studies were identified; 19 had a measurement of separate levels of mobility comparable to each other. Sixteen studies used ordinal and ratio scales without separate levels of mobility. The widest range of measurement found was the scale from 'walking with prosthesis without a walking aid' to 'totally confined to bed'. The Stanmore Harold Wood mobility scale was published most frequently. None of the 35 studies presented give a continuous measurement of mobility.

CONCLUSION

A multitude of measurement scales and questionnaires are available for differ in methods and measuring range. Measuring mobility by a scale has been shown to have limitations. Several authors did extensive research but they all measure only a number of aspects of mobility. Consensus about the measurement of mobility of lower limb amputees is not available in the recent literature.

A study of technical changes to lower limb prostheses after initial fitting

There is little published material in recent years about the use of lower limb prostheses in an elderly amputee population. In this study the authors were interested in the technical changes to lower limb prostheses after a first limb fitting procedure in a post-rehabilitation population in The Netherlands. The process of fitting a prosthesis and the technical changes to the artificial limb in the first year afterwards are studied.

Balloon angioplasty combined with primary stenting versus balloon angioplasty alone in femoropopliteal obstructions: A comparative randomized study

PURPOSE

To evaluate whether balloon angioplasty combined with stenting (ST) of symptomatic femoropopliteal disease would provide better results compared with balloon angioplasty alone (BA).

METHODS

Fifty-one patients were randomized between ST (24 patients) and BA (27 patients). Follow-up comprised clinical and hemodynamic assessment and color-flow duplex ultrasound examinations.

RESULTS

Residual stenosis (> or = 30% diameter reduction) occurred in three BA patients, but not in the ST patients. By life-table analysis the cumulative rate of clinical and hemodynamic success after 1 year with ST was 74% (SE 9%) and for those with BA 85% (SE 7%) (p = 0.25). The primary patency at 1 year assessed by color-flow duplex ultrasound was 62% (SE 9%) for ST-treated patients and 74% (SE 8%) for BA patients (p = 0.22). Occlusion occurred in five ST patients (21%) compared with two BA patients (7%).

CONCLUSION

ST does not improve clinical and hemodynamic outcome compared with BA. Moreover, the occlusion rate in ST-treated patients is higher.

Epidemiology of lower limb amputees in the north of The Netherlands: aetiology, discharge destination and prosthetic use

The aim of this study was to give a retrospective review of all lower limb amputations performed in the 3 northern provinces of the Netherlands in 1991-1992. Assembled data were compared with the existing information in the National Medical Register (NMR) over the same period. With the participation of all regional hospitals, 473 lower limb amputations from transpelvic to transmetatarsal level were identified. Of the amputations 94% were performed for vascular pathology, 3% for trauma, and 3% for oncologic reasons. After surgery a prosthesis was provided to 48% of the amputees. The actual number of performed amputations exceeds the number of amputations registered by the NMR by 9%. Incidence rates of lower limb amputations in the Netherlands are 18-20/100,000 over the last 12 years. These numbers are lower than in other areas and no sharp decrease in frequency compared with other countries in Western Europe.

Patterns of recurrent disease after recanalization of femoropopliteal artery occlusions

PURPOSE

In this prospective study we investigated the site, occurrence, and development of stenoses and occlusions following recanalization of superficial femoral artery occlusions.

METHODS

Recanalization of an occluded femoropopliteal artery was attempted in 62 patients. Follow-up examinations included clinical examination and color-flow duplex scanning at regular intervals. Arteriography was used to determine the localization of the recurrent disease relative to the initially occluded segment.

RESULTS

During a mean follow-up of 23 months (range 0-69 months) 14 high-grade restenoses, indicated by a peak systolic velocity ratio >> 3.0, were detected by color-flow duplex scanning. Occlusion of the treated segment occurred in 11 patients. The cumulative 3-year primary patency rate for high-grade restenoses and occlusions combined was 44% (SE 9%). By arteriographic examination the site of restenosis was localized in the distal half of the treated vessel segment in 16 of 21 cases.

CONCLUSION

Most restenoses and occlusions occurred during the first year and most disease developed at the previous intervention site. The site of restenosis is more frequently in the distal part of the initially treated segment, a finding that may have therapeutic implications.

The Günther temporary inferior vena cava filter for short-term protection against pulmonary embolism

PURPOSE

To evaluate clinically the Günther temporary inferior vena cava (IVC) filter.

METHODS

Eleven IVC filters were placed in 10 patients. Indications for filter placement were surgical pulmonary embolectomy in seven patients, pulmonary embolism in two patients, and free-floating iliofemoral thrombus in one patient. Eight filters were inserted from the right femoral approach, three filters from the left. Follow-up was by plain abdominal radiographs, cavography, and duplex ultrasound (US). Eight patients received systemic heparinization. Follow-up, during 4-60 months after filter removal was by clinical assessment, and imaging of the lungs was performed when pulmonary embolism (PE) was suspected. Patients received anticoagulation therapy for at least 6 months.

RESULTS

Ten filters were removed without complications 7-14 days (mean 10 days) after placement. One restless patient pulled the filter back into the common femoral vein, and a permanent filter was placed. In two patients a permanent filter was placed prior to removal. One patient developed sepsis, and one an infection at the insertion site. Clinically no recurrent PE developed with the filter in place or during removal. One patient had recurrent PE 7 months after filter removal.

CONCLUSION

The Günther temporary IVC filter can be safely placed for short-term protection against PE. The use of this filter is not appropriate in agitated or immunocompromised patients.

Clinical rehabilitation of the amputee: a retrospective study

The aim of this study was to determine the rehabilitation outcome of lower limb amputee patients after clinical rehabilitation. Altogether 183 amputee patients admitted for clinical rehabilitation in the years 1987-1991 were reviewed by retrospective analysis of medical record data. Three groups of amputee patients were identified by reason for amputation. The vascular group: (N = 132), mean age 67 years, mean admission time 119 days, 85% prosthetic fitting. The oncology group (N = 15), mean age 55 years, mean admission time 77 days, 60% prosthetic fitting. The traumatic amputee group: (N = 14), mean age 41 years, mean stay 134 days and 100% prosthetic fitting. Some 22 patients were bilateral amputees and were assessed separately. The most important reasons for not fitting a prosthesis were oncological metastases, stump and wound healing problems. After rehabilitation 86% of all patients could be discharged home. These results are more favourable than those seen in previous studies.

Congenital pelvic arteriovenous malformation: a rare cause of sciatica

A patient with a large congenital pelvic arteriovenous malformation presenting with irradiating pain to the leg, most likely due to sciatic nerve compression, is described. Congenital pelvic arteriovenous malformation are rare lesions, especially in males. Diagnosis was established by arteriography and contrast-enhanced computed tomography scan. Surgical resection of the AVM relieved our patient of all symptoms. However, endovascular therapy, either as primary treatment or followed by conventional surgery is the treatment of choice. Pelvic arteriovenous malformations should be considered in the differential diagnosis of unexplained sciatica.

Baló concentric sclerosis: MR diagnosis

An antemortem MR diagnosis of concentric sclerosis was made. After corticosteroid therapy the patient's symptoms diminished, and repeat MR revealed a decrease in the size of the lesion.

Functional outcome of rehabilitated bilateral lower limb amputees

The functional outcome of rehabilitated bilateral lower limb amputees was studied. The study included 31 amputees who were admitted during 1980-1990 to a rehabilitation centre in the north of the Netherlands. The clinical notes made during the patients' admission were studied to obtain information about their characteristics, while mobility and prosthetic use were studied at discharge. The patients who were alive and willing to participate in the study were interviewed by a physician at their residence in November 1992, using among other things, the Sickness Impact Profile (SIP) and the Life Satisfaction questionnaire. Some 25 of the 31 patients were amputated for vascular reasons, 1 patient primarily for traumatic reasons and secondarily for vascular reasons, 5 patients for traumatic reasons. Eight patients had a bilateral trans-femoral amputation, 18 patients a bilateral trans-tibial amputation, 2 patients a combination of trans-tibial and knee-disarticulation amputation, 3 patients a trans-femoral/trans-tibial amputation. Mean age at second amputation was 66.3 years. Of the 31 amputees 21 were men and 10 women, 25 amputees were prosthetically rehabilitated during admission, 3 of them died during admission and 5 did not achieve mobility at discharge. In their activities of daily life 22 of the 28 patients alive at discharge were almost independent. At the time of the follow-up evaluation 17 of the 31 patients had died. For several reasons only 8 patients could be included in the follow-up, 6 vascular amputees and 2 traumatic amputees.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between comfortable and most metabolically efficient walking speed in persons with unilateral above-knee amputation

Walking is most efficient when the least energy is spent over a certain distance. In six normal male subjects and 11 males with above-knee amputation the comfortable self-selected walking speeds and the most metabolically efficient walking speeds were determined. For that purpose energy expenditure was measured per second and per meter at six incremental walking speeds. Heart and step rate were registrated also at each walking speed. The results showed that in subjects who have not undergone amputation the comfortable walking speed is the same as the most efficient walking speed. However, in the above-knee amputee group, the comfortable walking speed is lower than the most efficient walking speed. When both groups walked at their own efficient walking speed they had the same energy expenditure per second.