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Biomedical subjects

C W Bakal

Publications and source records attributed to C W Bakal.

At least 19 recordsLinked to original sources
PubMed2000

Thrombolytic therapy with use of alteplase (rt-PA) in peripheral arterial occlusive disease: review of the clinical literature. The Advisory Panel.

PURPOSE: The clinical literature describing the use of alteplase in the treatment of peripheral arterial occlusive (PAO) disease is reviewed. MATERIALS AND METHODS: The literature database was acquired by a MEDLINE search using the Boolean keyword string: tissue plasminogen activator and/or rt-PA and peripheral not animal. A review was performed to identify the dose range of alteplase, technique of infusion, use of anticoagulation, clinical success rates, and risk of complications. RESULTS: Forty-six clinical studies were identified. There are few prospective, randomized clinical trials and a lack of standardized protocols and endpoints. Use of catheter-directed infusions of recombinant tissue plasminogen activator (rt-PA) may be beneficial versus surgery in the initial management of acute limb ischemia (< 14 days) and in reducing the magnitude of subsequent surgical or percutaneous revascularization. For patients with chronic limb ischemia (> 14 days), irreversible acute limb ischemia, or advanced diabetic arteriopathy, catheter-directed infusion of rt-PA or other plasminogen activators may be unsuitable. The risk of adverse bleeding appears related to the overall dose and duration of infusion. These risks appear similar to those of urokinase. The role of heparin in increasing adverse bleeding during rt-PA therapy is unclear. CONCLUSIONS: There is no generally accepted dose or technique for administering catheter-directed thrombolysis using alteplase; however, several studies have demonstrated its clinical safety and efficacy. Formal studies will be required to determine the optimal dose, technique of infusion, the role of anticoagulation, and complication rates when alteplase is used for PAO disease.

Arterial Occlusive Diseases↗
PubMed1997

Radiologic evaluation of penile arterial anatomy in arteriogenic impotence.

Functional and anatomic evaluation of penile arterial blood flow is essential in the work up of erectile dysfunction. Duplex ultrasonography is an ideal screening modality with cavernosal mean peak systolic blood flow velocity being the most sensitive predictor of arterial disease. Arterial variability of the penis may affect sonographic evaluation leading to frequent misinterpretation and therefore pudendal arteriography remains the current gold standard for penile arterial evaluation. Appreciation of the type and frequency of anatomic variants and potential collateral routes is important in interpreting penile arteriograms and in evaluating the hemodynamic significance of suspected arterial disease.

Arteries↗
PubMed1996

Endoluminal therapy with endovascular grafts.

The addition of balloon-expandable stents to conventional graft material allows minimally invasive repair of aortic and other aneurysms, arterial occlusions, and arterial trauma. Vascular access can be made at a site far from the pathology.

Aneurysm↗
PubMed1996

Endovascular aortounifemoral grafts and femorofemoral bypass for bilateral limb-threatening ischemia.

PURPOSE: Although axillobifemoral bypass procedures have a lower mortality rate than aortobifemoral bypass procedures, they are limited by decreased patency, moderate hemodynamic improvement, and the need for general anesthesia. This report describes an alternative approach to bilateral aortoiliac occlusive disease using unilateral endovascular aortofemoral bypass procedures in combination with standard femorofemoral reconstructions. METHODS: Seven patients who had bilateral critical ischemia and tissue necrosis in association with severe comorbid medical illnesses underwent implantation of unilateral aortofemoral endovascular grafts, which were inserted into predilated, recanalized iliac arteries. The proximal end of the endovascular graft was fixed to the distal aorta or common iliac artery with a Palmaz stent. The distal end of the graft was suture-anastomosed to the ipsilateral patent outflow vessel, and a femorofemoral bypass procedure was then performed. RESULTS: All endovascular grafts were successfully inserted through five occluded and two diffusely stenotic iliac arteries under either local (1), epidural (5), or general anesthesia (1). The mean thigh pulse volume recording amplitudes increased from 9 +/- 3 mm to 30 +/- 7 mm and from 6 +/- 2 mm to 26 +/- 4 mm ipsilateral and contralateral to the aortofemoral graft insertion, respectively. In all cases the symptoms completely resolved. Procedural complications were limited to one local wound hematoma. No graft thromboses occurred during follow-up to 28 months (mean, 17 months). CONCLUSIONS: Endovascular iliac grafts in combination with standard femorofemoral bypass grafts may be an effective alternative to axillobifemoral bypass in high-risk patients who have diffuse aortoiliac occlusive disease, particularly when bilateral axillary-subclavian disease is present.

Aged↗
PubMed1996

Infrapopliteal percutaneous transluminal angioplasty: what we know.

We believe that a substantial experience demonstrating the effectiveness and safety of infrapopliteal artery PTA has been accumulated. It is clear that the results of tibial PTA and femoropopliteal PTA are closely associated for most patients undergoing limb salvage procedures. Anatomic selection is most important; patients with focal disease and restorable runoff will generally benefit, and interventional radiologists should concentrate on treating this group of patients. PTA and surgery for limb salvage patients are indeed complementary procedures, and patients will benefit most by a methodical team approach to treatment. Problems with reporting of data in the literature have obscured the true effectiveness of distal PTA, with such deficiencies leading to both overestimation and underestimation of clinical utility. Nevertheless, the preponderance of evidence (as we see it) suggests a clinical effectiveness of about 80% at 2 years in appropriately selected patients. Like Dr. Fraser and his co-authors, we would welcome randomized trials of tibial PTA versus surgery, but even in the absence of these, the reporting of indications and results needs to be standardized: severity of symptoms at presentation and the extent of conservative treatments employed before intervention; life-table methodology on an intent-to-treat basis with clear delineation of end points; stratification by important variables such as lesion length, runoff status, extent of preexisting tissue loss, presence of diabetes and ESRD, and ideally, functional outcome and quality-of-life measures. Finally, we should learn from our surgical colleagues that close surveillance and early reintervention will probably increase the effectiveness of our percutaneous treatment methods.

Angioplasty, Balloon↗
PubMed1995

Placement of endovascular stented grafts via remote access sites: a new approach to the treatment of failed aortoiliofemoral reconstructions.

Endovascular grafting is a technique that combines the use of intravascular stents and prosthetic grafts to fabricate devices with unique properties. The purpose of this study is to describe the use of endovascular graft technology in the treatment of failed or failing standard aortoiliofemoral reconstructions. Over a 15-month period five patients with limb-threatening ischemia and failed aortofemoral or iliofemoral reconstructions underwent successful placement of six endovascular grafts to revascularize seven severely ischemic lower extremities. Standard thin-walled 6 mm polytetrafluoroethylene grafts and Palmaz balloon-expandable stents were used to fashion each reconstruction. In addition to the primary endovascular grafts, three patients underwent immediate femoropopliteal bypasses to improve distal outflow and one patient had a femorofemoral bypass graft to restore circulation to the contralateral ischemic extremity. The ankle/brachial indices of all patients significantly improved after the procedure (from a mean of 0.32 to a mean of 0.75) and all grafts are patent to date (mean follow-up 10 months). There were no deaths or limb loss in this group of patients. These favorable results indicate that this minimally invasive approach, which permits a new arterial graft to be inserted through a remote access site, is a valuable method for providing unobstructed arterial inflow after aortoiliofemoral graft failure. This procedure may be particularly valuable when there are contraindications to the use of axillary arteries or the thoracic aorta as alternatives to complex reoperative abdominal aortic surgery.

Aged↗
PubMed1995

Endovascular aortoiliac grafts in combination with standard infrainguinal arterial bypasses in the management of limb-threatening ischemia: preliminary report.

PURPOSE: Occlusive disease of the aortoiliac segment may lead to limb-threatening ischemia, if coexisting disease is present in the femoral, popliteal, or tibial arteries. The combined treatment of severe aortoiliac and infrainguinal disease with standard techniques may be hazardous or contraindicated in patients with multiple previous reconstructions, severe comorbid medical illnesses, or both. This report summarizes the technical feasibility and early results of aortoiliac endovascular stented grafts (ESGs) in combination with conventional surgical reconstructions for the treatment of multilevel arterial occlusive disease. METHODS: Seventeen patients with multilevel aortoiliofemoral limb-threatening occlusive disease had an ESG inserted to treat long-segment occlusive disease followed by a conventional surgical bypass. ESGs originated from the aortoiliac junction (seven) or the common iliac artery (10) and were inserted into the common femoral (nine), superficial femoral (four), or deep femoral (four) artery. ESG lengths ranged from 16 to 30 cm (mean, 21 cm). Conventional surgical bypasses were constructed from polytetrafluoroethylene (15) or saphenous vein (two) and extended to the popliteal (12), tibial (two), or contralateral femoral (three) arteries. RESULTS: Technical success in graft insertion was achieved in 17 (94%) of 18 attempted ESG procedures. The 1-year primary and secondary cumulative patency rates for ESGs were 94% +/- 10% and 100%, respectively, whereas the 1- and 2-year patency rates for the extravascular grafts were 92% +/- 10% and 100%, respectively. Four patients had minor postprocedure complications (23%), and no deaths occurred. One patient lost his limb at 16 months because of severe pedal sepsis. CONCLUSIONS: Transluminally placed stented grafts in combination with conventional surgical infrainguinal bypasses are a technically feasible and potentially safe option for the treatment of limb-threatening aortoiliofemoral occlusive disease and have demonstrated encouraging early patency. Long-term follow-up will be necessary before widespread application of this technique is advocated.

Adult↗
PubMed1995

Human transluminally placed endovascular stented grafts: preliminary histopathologic analysis of healing grafts in aortoiliac and femoral artery occlusive disease.

PURPOSE: The purpose of this study was to perform a preliminary histopathologic analysis of explanted human endovascular stented grafts from patients treated for occlusive disease. METHODS: Over a 16-month period, 26 endovascular stented grafts were placed in 21 patients with limb-threatening ischemia caused by aortoiliac or femoral artery occlusive disease. All grafts were inserted through open arteriotomies remote from the region of primary disease. During the follow-up period, two patients died of preexisting heart disease 2 weeks and 7 months after grafting, and a portion of their endovascular grafts were the surrounding artery was explanted. Specimens from five other endovascular grafts were obtained during surgical revision for graft stenosis after 3 and 6 weeks and for outflow artery stenosis after 3, 5, and 6 months. All specimens were formalin fixed and studied with hematoxylin and eosin and trichrome staining and immunohistochemically for factor VIII-related antigen, alpha actin smooth muscle, macrophage antigen (MAC-387) and PC-10 (a mouse monoclonal antibody which specifically recognizes proliferating cell nuclear antigen in paraffin sections). RESULTS: Three weeks after placement of the stented grafts, organizing thrombus was present on both surfaces of the expanded polytetrafluoroethylene (PTFE) grafts. At 6 weeks, evidence of a neointima with overlying endothelium was seen in the perianastomotic region, and 3 months after grafting it was seen 1 to 3 cm from the anastomosis. The specimen explanted at 5 months demonstrated factor VIII-positive cells 8 cm from the anastomosis. The histopathologic condition of the external capsule appeared to vary, depending on the presence or absence of an external wrap on the PTFE graft and on which layer in the arterial wall the graft was inserted. A foreign body reaction characterized by multinucleated giant cells was seen adjacent to wrapped grafts or around those placed in an intraadventitial plane. Grafts inserted within the media were surrounded by orderly, arranged, smooth muscle cells and few mononuclear cells. Extensive smooth muscle cell proliferation (PC-10 activity) was not seen within native artery atherosclerotic plaques peripherally displaced and external to prosthetic endovascular grafts. CONCLUSIONS: These preliminary observations on the healing of PTFE endovascular stented grafts in human beings demonstrate limited plaque hyperplasia and the presence of endothelial cells on the luminal surface remote from the graft-artery anastomosis. It is unclear whether this is a unique manifestation of healing in prosthetic grafts inserted within the walls of arteries.

Actins↗