[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to determine the rate of progression of the degree of carotid stenosis and to determine the risk of continued observation in a group of asymptomatic patients with moderate stenosis of at least one internal carotid artery. Between 1989 and 1994, 2130 patients were found to have 60-79% stenosis of at least one internal carotid artery following a duplex ultrasound examination in the authors' vascular laboratory. Of these, 465 patients (255 men, 210 women) were asymptomatic and had more than one ultrasound examination, and they form the basis of this retrospective review. The mean +/- SD age was 68.8 +/- 9.0 years. The mean +/- SD number of ultrasound examinations was 3.1 +/- 1.4 (range 2-11). The mean +/- SD follow-up was 24.4 +/- 17.6 months (range 2-79 months). Over the period of follow-up 72 patients (15.5%) progressed to 80-99% stenosis (n = 71) or to occlusion (n = 1). The estimated percentage of patients who progressed by life table methods were 5 +/- 1% at 1 year, 11 +/- 2% at 2 years and 20 +/- 3% at 3 years. There was no statistically significant difference in the rate of progression in men compared with women. Twenty-one patients had a late ipsilateral TIA or stroke. Five out of 72 patients (6.9%) who progressed had a late ipsilateral TIA compared with nine out of 393 patients (2.3%) who did not progress (estimated risk ratio 16.1, P = 0.0001). Four out of 72 patients (5.6%) who progressed had a late ipsilateral stroke compared with three out of 393 patients (0.76%) who did not progress (estimated risk ratio 23.6, p = 0.0002). The cumulative ipsilateral stroke rate using life table methods was 0.22% at 1 year, 1% at 2 years and 2.4% at 3 years. In a large cohort of asymptomatic patients, the frequency of progression of 60-79% internal carotid artery stenosis was 5% at 1 year, 11% at 2 years and 20% at 3 years. Patients who progressed were more likely to have symptoms, but the rate of unheralded stroke was relatively low over a 3-year time period. Surveillance carotid ultrasound examinations should be performed in patients with moderate carotid stenosis. Because of the lack of clear benefit, carotid endarterectomy for asymptomatic 60-79% internal carotid artery stenosis cannot be justified.
Vascular Medicine 02/1998; 3(2):101-8. · 1.62 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Atherosclerotic carotid artery stenosis (CAS) is the most common cause of stroke in young adults. We retrospectively studied clinical characteristics of premature CAS and the safety and durability of carotid endarterectomy (CEA) in 56 patients 50 years of age or younger (mean, 46.4 years; 34 (60%) males; group I) who underwent primary CEA at the Cleveland Clinic between 1983 and 1993.
The patients were identified from the Vascular Surgery Registry and were compared with 202 randomly selected patients 60 years of age and older (mean, 69.3 years; group II) who were frequency-matched by gender and the year of primary CEA. Carotid shunting was used routinely, and the arteriotomy was patched in the majority of cases. Patients were followed-up for mean of 47.2 months (group I) and 46.0 months (group II).
No significant differences were found in the indications for CEA (symptomatic CAS, 49% in group I vs 48% in group II) or the prevalence of diabetes, coronary diseases, and lower extremity arterial disease. Younger adults were more likely to have a history of smoking (93% vs 76%; p = 0.005), hypertension (71% vs 52%; p = 0.006), premature menopause (57% vs 18%; p < 0.001) and had lower levels of high-density lipoprotein cholesterol (p = 0.03). There were no in-hospital deaths. Perioperative strokes in the distribution of the operated artery occurred within 24 hours in one younger patient (1.8%) and in one older patient (0.5%). This was attributed to early carotid thrombosis in the young patient. Major late postoperative neurologic complications were documented in one young patient (1.8%) and six older patients (3%). Patients in group I were at significantly higher risk for recurrent carotid stenosis (risk ratio, 3.1; 95% confidence interval [CI], 1.3 to 7.3; p = 0.010); younger individuals remained at significantly higher risk for recurrent stenosis even after adjusting for smoking and hypertension (risk ratio, 3.7; 95% CI, 1.5 to 9.4; p = 0.006). By life-table analysis, younger adults tended to have a higher rate of late reoperations (p = 0.065).
CEA can be safely performed in young adults with premature CAS, although younger individuals appear to have higher rates of recurrent carotid stenosis compared with older counterparts.
Journal of Vascular Surgery 02/1997; 25(2):326-31. · 2.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the efficacy of intravascular stents used to treat long-segment stenoses and occlusions of the superficial femoral artery (SFA) after suboptimal angioplasty.
Fifty-eight limbs in 55 patients who underwent stenting of the SFA were identified from a vascular registry. Indications for stent placement after suboptimal PTA included flow-limiting dissection, residual pressure gradient (>15 mm Hg) or stenosis (>30%), or failure to establish initial patency. Lesion length ranged from 6 to 35 cm (mean, 16.5 cm). Endpoints for primary patency were: restenosis of >50%, reocclusion, or diminution of the postprocedure ankle-brachial index greater than 0.15.
The mean ankle-brachial index improved from 0.48 +/- 0.19 to 0.71 +/- 0.23 (p = 0.001). Primary patency rates by Kaplan-Meier estimates at 1 month, 6 months, and 1 year were 88%, 47%, and 22%, respectively. Secondary patency rates were 94% at 1 month, 59% at 6 months, and 46% at 1 year. The median time to reaching an endpoint of restenosis or reocclusion was 6 months primarily and 9 months secondarily. Clinical improvement at the time of latest follow-up occurred in 56% of patients (mean, 13.8 months). Periprocedural complications occurred in 24.5% of patients with the first intervention. The only factor that favorably influenced outcome was improvement in clinical category after the procedure (p = 0.001).
There was a high incidence of restenosis and reocclusion with long-segment SFA disease that required stents to achieve initial success. Despite close surveillance and reintervention, anatomic patency at 1 year was poor. However, clinical benefit was maintained in the majority of patients. The outcome was similar in the claudication population compared with those who had limb-threatening ischemia. Percutaneous revascularization of long-segment SFA disease requiring stents should be reserved for patients with critical limb ischemia for which no reasonable surgical alternative exists.
Journal of Vascular Surgery 01/1997; 25(1):74-83. · 2.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Preoperative clinical indexes to stratify cardiac risk have not been validated angiographically. Our aims were to determine the concordance of clinical risk with severity of coronary stenosis and to develop and validate a preoperative clinical index to exclude the presence of significant coronary stenosis.
We carried out a prospective study of 878 consecutive patients (including the derivation and validation sets). "Severe" stenosis was defined as three-vessel (> or = 50% stenosis in each), two-vessel (> or = 50% stenosis in one when the other is > or = 70% stenosis of the left anterior descending), or left main disease (> or = 50%); "critical" stenosis was three-vessel (> or = 70% stenosis in each) and/or left main stenosis > or = 70%. A preoperative clinical index (diabetes mellitus, prior myocardial infarction, angina, age > 70 years, congestive heart failure) was used to stratify patients. A gradient of risk for severe stenosis was seen with increasing numbers of clinical markers. The following prediction rules were developed: The absence of severe coronary stenoses can be predicted with a positive predictive value of 96% for patients who have no (1) history of diabetes, (2) prior angina, (3) previous myocardial infarction, or (4) history of congestive heart failure. The absence of critical coronary stenoses can be predicted with a positive predictive value of 94% for those who have no (1) prior angina, (2) previous myocardial infarction, or (3) history of congestive heart failure.
By reliably identifying a large proportion of patients with a low likelihood of significant stenoses, these prediction rules can help to substantially reduce healthcare costs associated with preoperative cardiac risk assessment for noncardiac surgery.
[Show abstract][Hide abstract] ABSTRACT: In a case-control study of 63 patients undergoing major nonthoracic vascular surgery with prior cardiac catheterization, we found total coronary occlusion serving viable myocardium and "nonobstructive" lesions to be the most common proximate cause of perioperative myocardial infarction or death. The extent of coronary disease by several measures was significantly correlated with adverse outcome, and prior bypass surgery appeared to be protective.
The American Journal of Cardiology 06/1996; 77(12):1126-8. · 3.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Data from our institution and elsewhere have demonstrated that ultrasound-guided compression closure (UGCC) is an effective method of treating postcatheterization pseudoaneurysms. Whereas patients receiving anticoagulation do not have as high a success rate as those not receiving anticoagulants, there have been no large series evaluating the factors associated with success or failure in patients receiving anticoagulation. The purpose of this study is to determine whether uninterrupted anticoagulation interferes with successful UGCC of pseudoaneurysms and to identify factors associated with success or failure.
From May 1991 to September 1994, 238 cases of attempted UGCC of pseudoaneurysms were performed in our vascular laboratory. Only patients who received uninterrupted heparin, warfarin, or both at the time of pseudoaneurysm compression were eligible for inclusion into the study. Seventy-seven patients were identified who met the study criteria.
Successful pseudoaneurysm compression was obtained in 56 (73%) patients, whereas 21 (27%) patients had a failed UGCC. In the successfully treated group, seven (12.5%) required between two to three compression attempts to induce sustained thrombosis. There was no statistical difference in age, sex, sheath size, days after procedure, location of pseudoaneurysm, or number of chambers in the pseudoaneurysm between those patients who had a successful repair and those who did not. If the pseudoaneurysm was less than 4 cm in diameter, 51 of 65 patients (78%) had a successful repair compared with 5 of 12 patients (42%) with a pseudoaneurysm of 4 cm or greater (p = 0.013). There was no statistical difference between success and failure in patients receiving warfarin alone (3.73 mean international normalized ratio, 72% success rate), heparin alone (mean activated partial thromboplastin time of 63 seconds, 92% success rate), or heparin and warfarin (mean activated partial thromboplastin time of 70 seconds, mean international normalized ratio of 4, success rate of 67%). No arterial or venous thrombosis occurred during pseudoaneurysm compression.
Successful UGCC of pseudoaneurysms occurred in a large percentage of patients receiving full-dose, uninterrupted anticoagulation. The only factor influencing success was the size of the pseudoaneurysm.
Journal of Vascular Surgery 02/1996; 23(1):28-34, discussion 34-5. · 2.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine whether heparin administered by continuous intravenous infusion using a nomogram is superior to a random dosing scheme, we performed a prospective, randomized comparative trial in 161 patients. Patients were prospectively randomized to one of three groups. Group I received an intravenous bolus of 5000 IU of heparin followed by heparin administration according to a modification of a previously published nomogram. Group II patients received a 5000 IU intravenous bolus of heparin followed by continuous intravenous heparin infusion with dosage adjustment at the discretion of the treating physician. Group III patients received a continuous intravenous heparin infusion with dosage adjustments at the discretion of the treating physician without the prior administration of a bolus dose. Activated partial thromboplastin time (APTT) was obtained at baseline, 6 h after each heparin dose adjustment and every morning. The mean percent of each patient's APTTs in the subtherapeutic range (< 50 sec) over the course of treatment was 9% for group I and 24% for groups II and III, p = 0.0001. The three groups had a similar percentage of each patient's APTTs within the therapeutic range (50-80 sec). There was a larger percentage of APTTs > 80 sec in group I (46%) compared to group II (31%) or group III (32%), p = 0.01. There were no clinically recurrent deep venous thrombi or arterial thromboemboli in any of the groups. Two patients had documented pulmonary emboli during heparin therapy (one in group I; one in group II). There was no difference in the complication rates of heparin therapy or the need for blood transfusions among the three groups. Patients randomized to the heparin nomogram (group I) achieved an APTT > 50 sec more frequently than patients in the other two groups. Overall, fewer patients in the nomogram group were subtherapeutic, and, when APTT levels fell in the subtherapeutic range, the nomogram restored APTTs to the therapeutic range faster than the standard methods. The heparin nomogram was clearly more effective as a method of heparin dosing than standard methods of anticoagulation dosing.
Vascular Medicine 01/1996; 1(2):97-101. · 1.62 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the utility of duplex ultrasound scanning of the renal arteries in identifying patients with renal artery stenosis of 60% or more and in excluding patients with either normal renal arteries or renal artery stenosis of less than 60%.
A prospective, blinded study.
Large tertiary referral center.
102 consecutive patients (44 men and 58 women with a mean age [+@- SD] of 63.3 +/- 13.4 years) who had both duplex ultrasound scanning of the renal arteries and renal arteriography. All patients who were studied had hypertension that was difficult to control, unexplained azotemia, or associated peripheral vascular disease (alone or in combination), giving them a high pretest likelihood of renovascular disease.
Peak systolic and end diastolic velocities, renal-aortic ratios, resistive index, and kidney sizes.
Sixty-two of 63 arteries with stenosis of less than 60% using arteriography were correctly identified by duplex ultrasound scanning. Thirty-one of 32 arteries with 60% to 79% stenosis using arteriography were correctly identified as having 60% to 99% stenosis on duplex ultrasound, whereas 67 of 69 arteries with 80% to 99% stenosis on arteriography were correctly identified as having 60% to 99% stenosis on ultrasound. Twenty-two of 23 arteries with total occlusion on arteriography were correctly identified by duplex ultrasound. The overall sensitivity of duplex ultrasound compared with arteriography was 0.98, the specificity was 0.98, the positive predictive value was 0.99, and the negative predictive value was 0.97.
Duplex ultrasound scanning of the renal arteries is an ideal screening test because it is noninvasive and can predict the presence or absence of renal artery stenosis with a high degree of accuracy.
Annals of internal medicine 07/1995; 122(11):833-8. · 13.98 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The purpose of this report is to describe the indications, technique, and results for ultrasound-guided compression repair (UGCR) of postcatheterization pseudoaneurysms at a large medical center in which catheter-based diagnostic and interventional procedures are frequently used.
We reviewed the initial series of 100 consecutive patients who underwent UGCR in our noninvasive vascular laboratory from May 1991 through August 1992. Nearly all (n = 95) of these pseudoaneurysms involved the common femoral artery or its major branches, and each was manually compressed with a 5 MHz linear transducer for 10-minute intervals until the pseudoaneurysm was completely occluded or the procedure was considered to be a failure.
UCGR was immediately successful in 94 patients, including 30 (86%) of 35 patients who were receiving anticoagulants and 64 (98%) of the 65 who were not (p = 0.019). The average compression time to achieve occlusion was 33 minutes (range 10 to 120 minutes), but was nearly twice as long (51 minutes) for pseudoaneurysms that had been present for more than 14 days. There were no related complications, but recurrent pseudoaneurysms occurred in six (20%) of 30 patients who continued to receive formal anticoagulation, compared with only four (6%) of 64 who did not (p = 0.074). Eight of the 10 recurrences were discovered within 24 hours after primary UGCR, but two others presented at 16 and 35 days, respectively. Eight recurrent lesions were corrected by repeat UGCR, whereas the remaining two required surgical repair.
UGCR provides a reliable alternative to surgical treatment for postcatheterization pseudoaneurysms. Adequate follow-up is important, however, especially in patients for whom continued anticoagulation is necessary.
Journal of Vascular Surgery 05/1994; 19(4):683-6. · 2.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Fifty consecutive patients undergoing abdominal aortic aneurysm resection were studied prospectively for the presence of deep venous thrombosis (DVT) after surgery.
Bilateral venography was performed 5 days after surgery in all patients. There were 42 men and 8 women, with a mean age of 70 years (range 60 to 83 years). No patients received DVT prophylaxis before surgery.
Nine (18%) of 50 patients had a venogram positive for acute DVT. Nine (21%) of 42 men and none of eight women had DVT. Six patients had DVT in the left leg and three patients in the right leg. No patients had symptoms to suggest DVT. Seven (78%) of the nine patients with DVT had thrombi in the calf veins and two patients (22%) had thrombi in the more proximal venous segments, representing 14% and 4% of the entire series, respectively. No clinically evident pulmonary emboli were observed.
Eighteen percent of 50 consecutive patients undergoing abdominal aortic aneurysm resection had DVT. Because of this high incidence, a study should be undertaken to determine whether DVT prophylaxis can lower the incidence of DVT after abdominal aortic aneurysm resection.
Journal of Vascular Surgery 01/1994; 18(6):1037-41. · 2.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Between 1977 and 1991, 405 patients with atherosclerotic occlusive disease of the superficial femoral artery underwent clinical as well as noninvasive laboratory evaluation and were recommended for nonoperative treatment.
Limbs with uncorrected aortoiliac occlusive disease, aneurysmal degeneration, or previous femoropopliteal bypass were excluded, leaving 568 involved extremities. Complete follow-up, which forms the basis for this report, was available in 377 patients (93%) with 520 limbs (93%). Patients were monitored for a minimum period of 2 years (range, 24 to 164 months; median, 86 months). During the surveillance period 45 limbs (8.6%) in 42 patients (11.1%) required arterial intervention. This entailed operation in 39 cases and endovascular treatment in six cases. With use of life-table analysis, the risk for intervention was found to be 11% at 5 years and 14% at 10 years. A total of 14 limbs (2.7%) in 14 patients (3.7%) ultimately required major limb amputation, either after failed bypass (8 patients) or as a primary procedure (6 patients).
Analysis of risk factors revealed that female sex (p = 0.04), chronic renal failure (p = 0.0001), diabetes mellitus (p = 0.0011), history of contralateral femoropopliteal bypass (p = 0.0005), level of disease (p = 0.003), and entry ankle/brachial index less than 0.50 (p = 0.004) were associated with an increased risk over time for intervention. Other factors, including age, current or prior smoking history, hypertension, and the presence of coronary artery disease or cerebrovascular disease failed to reach statistical significance.
These data support the continued conservative approach to surgery for patients with superficial femoral artery occlusive disease without limb-threatening symptoms. Patients with multilevel disease, lower ankle/brachial index, a history of contralateral femoropopliteal bypass, chronic kidney failure, or diabetes mellitus are at increased risk and should be monitored more closely.
Journal of Vascular Surgery 02/1993; 17(1):172-81; discussion 181-2. · 2.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The prevalence of abnormal lipid and lipoprotein values was determined in 125 consecutive patients with lower-extremity arteriosclerosis obliterans, and the lipid and lipoprotein abnormalities in these patients were characterized. Only 13% of the patients had normal lipid/lipoprotein profiles. Forty-eight percent of patients had low levels of high-density lipoprotein cholesterol. High-density lipoprotein cholesterol values were lower in patients with concomitant coronary heart disease compared with those without heart disease. High-density lipoprotein cholesterol values were inversely related to weight, to triglyceride values, and to diabetes mellitus. Twenty-eight percent of patients had "desirable" total cholesterol levels (< 200 mg/dL), and 32% had low-density lipoprotein cholesterol values less than 130 mg/dL. Following National Cholesterol Education Program guidelines may be misleading in patients with documented lower-extremity atherosclerosis; therefore, complete lipid/lipoprotein profiles should be performed in these patients.
Cleveland Clinic Journal of Medicine 01/1992; 59(5):491-7. · 3.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The experience at the Cleveland Clinic from 1982 to 1990 using thrombolytic therapy for superior vena cava (SVC) syndrome was retrospectively reviewed. Sixteen patients, 11 of whom had indwelling central venous catheters, were treated with either urokinase (n = 11) or streptokinase (n = 5). Either urokinase (4,400 U/kg bolus followed by 4,400 U/kg/h) or streptokinase (250,000 U bolus followed by 100,000 U/h) was used, and venograms were performed before and after. Overall, 56 percent of patients had complete clot lysis and relief of symptoms. Thrombolytic therapy was effective in eight (73 percent) of 11 patients receiving urokinase and one (20 percent) of five patients receiving streptokinase. Of those with a central venous catheter, eight (73 percent) of 11 patients were successfully lysed, whereas only one (20 percent) of five patients was successfully lysed if no catheter was present. If thrombolytic therapy was performed less than or equal to five days of symptom onset, seven (88 percent) of eight patients were successful, if thrombolytic therapy was performed greater than five days after symptom onset, two (25 percent) of eight patients were successful. Symptoms were relieved and the catheter was preserved in patients in whom thrombolytic therapy was effective. Factors predicting success were as follows: (1) the use of urokinase compared with streptokinase; (2) the presence of a central venous catheter; and (3) a duration of symptoms less than or equal to five days.
[Show abstract][Hide abstract] ABSTRACT: Between 1970 and 1987, 112 patients were diagnosed as having thromboangiitis obliterans (TAO). The age was 42 +/- 11 years (mean +/- SD; range, 20-75 years); 23% were women, and 7% were more than 60 years old when they were first diagnosed. Ischemic ulcerations were present in 85 (76%) patients: 24 (28%) patients with upper-extremity, 39 (46%) patients with lower-extremity, and 22 (26%) patients with both upper- and lower-extremity lesions. Ninety-one (81%) patients had rest pain, 49 (44%) patients had Raynaud's phenomenon, and 43 (38%) patients had superficial thrombophlebitis. We were able to follow up 89 of the 112 (79%) patients for 1-460 months (mean follow-up time, 91.6 +/- 84 months). Sixty-five (73%) patients had no amputations, while 24 (27%) had one or more of the following amputations: finger, six (15%) patients; toe, 13 (33%) patients; transmetatarsal, four (10%) patients; below knee, 14 (36%) patients; and above knee, two (5%) patients. Forty-three (48%) patients stopped smoking for a mean of 80 +/- 105 months (median, 46.5 months; range, 1-420 months), and only two (5%) patients had amputations after they stopped smoking, while 22 (42%) patients had amputations while continuing to smoke (p less than 0.0001). The spectrum of patients with TAO is changing in that the male-to-female ratio is decreasing (3:1), more older patients are being diagnosed, and upper-extremity involvement is commonly present. In the 48% of patients who stopped smoking, amputations and continued disease activity were uncommon.
[Show abstract][Hide abstract] ABSTRACT: To determine the prevalence of atherosclerotic renal artery stenosis in patients who have atherosclerosis elsewhere but lack the usual clinical clues to suggest renal artery stenosis.
The arteriograms and charts of 395 consecutive patients were prospectively reviewed by a member of the Vascular Medicine Department and a member of the Radiology Department. These patients underwent arteriography as part of the routine evaluation for abdominal aortic aneurysm (109 patients), aorto-occlusive disease (21 patients), lower-extremity occlusive disease (189 patients), and suspected renal artery stenosis (76 patients). Patients in the first three groups did not have the usual clues that suggest renal artery stenosis.
There was greater than 50% renal artery stenosis in 41 patients (38%) with abdominal aortic aneurysm, seven patients (33%) with aorto-occlusive disease, 74 patients (39%) with lower-extremity occlusive disease, and 53 patients (70%) with suspected renal artery stenosis. The prevalence of renal artery stenosis was similar in diabetic and nondiabetic patients with abdominal aortic aneurysm, aorto-occlusive disease, or suspected renal artery stenosis, but higher in diabetics with lower-extremity occlusive disease (50%) compared to nondiabetics with lower-extremity occlusive disease (33%) (p = 0.022). High-grade bilateral disease was present in approximately 13% of patients with abdominal aortic aneurysm or lower-extremity occlusive disease, and totally occluded renal arteries occurred in 5% of the patients in these groups. There was an association between increasing degree of renal artery stenosis and the presence of hypertension and worsening of renal function.
Patients with atherosclerosis elsewhere, especially abdominal aortic aneurysm, aorto-occlusive disease, or lower-extremity occlusive disease, have a high prevalence of significant renal artery stenosis even in the absence of the usual clues to suspect renal artery stenosis. Diabetic patients have a similar prevalence as nondiabetic patients. This information may have important therapeutic implications in patients being considered for vascular surgery.
The American Journal of Medicine 02/1990; 88(1N):46N-51N. · 5.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Percutaneous transluminal angioplasty and renal artery revascularization have been successful in controlling blood pressure and preserving renal function in patients with atherosclerotic renal artery stenosis. In addition, thrombolysis appears promising for treatment of patients with total occlusion of renal artery bypass grafts. More experience will be necessary to define its role in native renal artery occlusions. The authors describe successful thrombolysis in two of three patients given thrombolytic therapy for total occlusion of renal arteries.
Cleveland Clinic Journal of Medicine 07/1989; 56(4):432-8. · 3.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Twenty-two patients were selected from a group of 33 patients who underwent recombinant human tissue-type plasminogen activator (rt-PA) thrombolysis for thrombosed infrainguinal bypass grafts of the lower extremity and were compared with 38 matched patients who had undergone surgical thrombectomy during the same period. The proportion of persons with diabetes mellitus, smokers, and types of bypass grafts was similar in both groups. More patients in the rt-PA-treated group had hypertension (p = 0.01). To evaluate the different lengths of follow-up, Kaplan-Meier survival analysis was used with a log-rank test to compare the proportion of persons with patent grafts in the two treatment groups. At 30 days, 86% of the rt-PA-treated grafts were still patent compared with 42% of the surgically treated grafts (p = 0.001). When risk factors on the Kaplan-Meier curves were compared, there was no statistical difference with regard to graft patency among the groups. According to simultaneous Cox regression analysis, no risk factor was significantly associated with graft patency. When amputation was evaluated between treatment groups simultaneously with other risk factors in a logistic regression analysis, smoking and age of the graft were marginally significant (p = 0.07), whereas all other factors were clearly not significant. In 91% of the rt-PA-treated patients, a secondary surgical procedure was required to maintain patency of the graft segment. Eighty-nine percent of the surgically treated patients required similar graft revisions. Two patients in the surgical group and one patient in the rt-PA-treated group had major complications.(ABSTRACT TRUNCATED AT 250 WORDS)
Journal of Vascular Surgery 03/1988; 7(2):347-55. · 2.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is a common belief that administration of anticoagulants to patients with brain tumors is contraindicated. Between 1982 and 1986, 50 patients with deep venous thrombosis and pulmonary emboli and brain tumors were examined and treated. Twenty-four patients received an inferior vena cava Greenfield filter and 25 patients were treated with anticoagulants. One patient was terminal and received no therapy. Patients in each group were similar with regard to age, sex, primary tumor, computed tomographic findings, and ultimate outcome. At the time of diagnosis, all patients had residual tumor and most had significant cerebral edema and midline shift. There were no complications in the group receiving Greenfield filters. One patient had a pulmonary embolus after the filter was placed and later required anticoagulant therapy. In the group receiving anticoagulants, one patient had focal intraventricular bleeding observed incidentally on computed tomographic scan one month after beginning anticoagulant therapy and was totally asymptomatic. One patient had gastrointestinal tract bleeding five days after beginning anticoagulant therapy with heparin sodium, and the therapy was therefore discontinued. No other patient had significant bleeding. In view of these findings, a reevaluation of anticoagulant therapy in patients with central nervous system tumors is warranted.
Archives of Internal Medicine 01/1988; 147(12):2177-9. · 11.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study examines the comparative efficacy, safety, and cost associated with treatment of deep vein thrombosis with streptokinase or urokinase. Sixty patients were analyzed retrospectively, 30 treated with streptokinase and 30 treated with urokinase. Statistically significant greater fibrinogenolysis was noted when streptokinase was used to treat patients with deep venous thrombosis (p = 0.01). The mean decrease in fibrinogen from preinfusion value was 83% in the streptokinase treated group and 61% in the urokinase treated group. Five of 30 (17%) of the streptokinase treated patients experienced major complications. No major complications were seen in the urokinase treated group (p = 0.019). Cost analysis demonstrates that therapy with urokinase was $11.40 per patient more than streptokinase. If complications are not included in the cost analysis, then urokinase becomes only $650 per patient more expensive than streptokinase therapy. These data support that deep vein thrombosis treatment with urokinase is effective, safer and more cost efficient when compared to streptokinase.
Annals of Vascular Surgery 01/1988; 1(5):524-8. · 0.99 Impact Factor