PubMed Health⌕ Search

Biomedical subjects

M Leschke

Publications and source records attributed to M Leschke.

At least 19 recordsLinked to original sources
PubMed1998

[Duplex ultrasound risk stratification of percutaneous puncture of the brachial artery for diagnostic and interventional coronary angiography].

Diagnostic and interventional heart catheterization in peripheral vascular disease often requires due to iliacal disease additional methods of arterial approach besides the Judkin's technique. The percutaneous catheterization of the brachial artery finds widespread use. A major complication linked with this method is an increased rate of thrombotic occlusions at the puncture site. Thus, we investigated in a prospective set-up the ability of duplex ultrasound to identify predictive risk factors for vascular complications. Over a period of 20 months, 8000 patients referred to heart catheterization were studied. Routine catheterization via the femoral route was contraindicated in 34 out of 8000 mostly due to severe peripheral vascular disease with multiple vascular risk factors (diabetes, hypertension, and smoking). 53 patients who had a comparable low risk-profile served as the control group. The brachial artery was examined by ultrasound duplex for vessel anatomy and diameter at the puncture site before coronary angiography. Both groups (patient and control group) showed in 15% a variable anatomy with a premature division of the brachial artery in 6% proximal of the elbow and in 9% already distal to the axillary artery. Because of reduced diameters of these variable vessels no procedure was carried out at these arms. In all cases the opposite arm was successfully used instead, because the variants were always located only at one arm. The diameter of the brachial artery measured in average 5.0 +/- 0.8 mm and 4.8 +/- 0.7 mm in patients and controls, respectively. Women had a significantly smaller vessel diameter than men, measuring a difference of 0.4 and 0.6 mm, respectively (p < 0.05). For coronary angiography 6F and 7F arterial sheats were used equally, and in 32% of all cases a coronary intervention was performed. 31 (91%) procedures were carried out without complications; there was a false aneurysm in 1 patient (3%) and an occlusion of the brachial artery at the puncture site in 2 patients (6%). The occluded vessels of two diabetic women had a reduced diameter at the level of 10% of the standard distribution and an unfavorable ratio of sheat-to-vessel-diameter which lead initially to an obstruction of nearly 50% of the vessel lumen during catheterization. Screening of the brachial artery by ultrasound duplex before a percutaneous catheterization for coronary angiography and intervention showed reproducibly the variable anatomy and differences in vessel diameter, which can be risk factors for thrombotic occlusion. Important details for the location of the puncture site and the possible size of the arterial sheat can be obtained, so that coronary interventions with 7F catheter systems are still practicable. This technique is a simple and efficient method to estimate the relative risk of arterial occlusion prior to percutaneous puncture of the brachial artery, especially in a group of patients with severe atherosclerosis and elevated vascular risk-factors.

Adult↗
PubMed1998

Haemolytic-uraemic syndrome and thrombotic-thrombocytopenic purpura in adults: clinical findings and prognostic factors for death and end-stage renal disease.

BACKGROUND: Left untreated, haemolytic-uraemic syndrome (HUS) and thrombotic-thrombocytopenic purpura (TTP) in adults have a poor prognosis with mortality rates reaching 90%. Patients who survive often develop end-stage renal disease. Because of similarities in clinical and morphological findings, both diseases are considered as one entity referred to as HUS-TTP syndrome. METHODS: From 1974 to January 1995, 45 adult patients received treatment for HUS-TTP at our clinic. By stepwise logistic regression analyses, we examined how known risk factors and plasma exchange with fresh-frozen plasma (PE) influenced mortality and end-stage renal disease. RESULTS: Three of 45 patients died (7%). Though we were not able to find significant predictors of mortality, low haemoglobin levels (5.93 +/- 0.32 vs 9.10 +/- 2.16 g/dl) and high leukocyte counts on admission (15.830 +/- 3.690 vs 11.150 +/- 4.580 microliters-1) appeared to indicate an unfavourable outcome. Regarding the development of end-stage renal disease, PE proved to be the only favourable indicator (P = 0.0001). PE was performed in 30 patients 3-20 times (9.2 +/- 4.8, mean +/- SD). Of 28 surviving patients treated with PE, only four developed end-stage renal disease, whereas dialysis was necessary in 11 of 14 patients not treated with PE. Application of PE led to an 81.8% reduction of the relative risk of developing end-stage renal disease. An additional prognostic influence of other potential risk factors such as age, sex, platelet count on admission, lactate dehydrogenase serum levels, serum creatinine, blood pressure, prodromal disease, and renal histology was not found. CONCLUSION: This retrospective clinical study confirms the therapeutic value of plasma exchange with fresh-frozen plasma to maintain renal function in patients with HUS-TTP.

Adolescent↗
PubMed1997

Long-term survival of recipients of allogeneic bone-marrow transplantation after mechanical ventilation.

To evaluate the prognostic significance of mechanical ventilation for outcome of intensive care therapy for pulmonary complications after allogeneic bone marrow transplantation (aBMT) we analysed the clinical course of ten patients requiring intubation and mechanical ventilation after aBMT for pulmonary complications. Ten out of eighty-five patients (12%) undergoing aBMT between 1989 and 1995 required mechanical ventilation for pulmonary complications at our university adult intensive care unit (ICU). Ventilation could be discontinued in four patients after pulmonary function improved. Three of these patients are long-term survivors after two to five years (median 37 months) of follow-up. Significant differences between the two groups of survivors (n = 4 patients) and non-survivors (n = 6 patients) which could have an impact on prognosis exist for graft-versus-host-disease (GvHD), (p < 0.04) and the time between aBMT and intubation (p < 0.05). There were no differences for age (median: 36 and 34 years of age respectively), laboratory values, duration of mechanical ventilation (median: 7 days for both groups) and APACHE-scores. In survivors, mechanical ventilation became necessary because of atelectasis or obstruction by mucositis in two cases, septicemia with concomitant ARDS in one case and bacterial pneumonia in one case. In non-survivors, pulmonary complications were caused by infections. Causes of death were septicemia or septic shock in five cases and GvHD-induced bronchiolitis obliterans in one case. In conclusion patients at risk for fatal outcome after intensive-care therapy for pulmonary complications following aBMT show a higher degree of GvHD, more infectious complications and a later onset of ventilation after aBMT. With an overall longterm-survival of 3 out of 10 patients, mechanical ventilation seems to be live-saving in a selected subset of patients.

Adult↗
PubMed1997

[Conservative therapeutic approaches in terminal coronary heart disease. Chronic intermittent urokinase therapy].

Despite progress in the invasive revascularization procedures and even though conventional antianginal treatment has improved the quality of life in patients with symptomatic coronary artery disease considerably, an increasing number of patients suffers from end-stage coronary artery disease and refractory angina pectoris. For these refractory patients long-term intermittent urokinase therapy was developed as an antithrombotic intervention, which is based on its capacity to enhance thrombolysis and blood rheology, and may possibly lead to plaque regression. The coronary syndrome of refractory angina pectoris is characterized by a mismatch of severe coronary insufficiency and a relatively large amount of viable myocardium as indicated by an only moderately impaired left ventricular function. Prior to initiation of long-term intermittent urokinase therapy all potential measures to improve myocardial perfusion have to be considered in each patient. These supportive measures include rigorous reduction of LDL-cholesterol, which has proven antiischemic properties due to an improved endothelial function of epicardial conductance vessels possibly resulting in an antianginal effect. Apart from the proven antiischemic properties of long-term intermittent urokinase therapy in patients with refractory angina pectoris, objective signs of ischemic myocardial heart failure improve. Follow-up studies demonstrated a significant increase of left ventricular ejection fraction as evaluated with multi-gated blood pool analysis. Furthermore, left ventricular diastolic function normalized after a treatment period of 12 weeks. As the clinical effects last well beyond the actual treatment period and as they are accompanied by a remarkable increase in the quality of life, a complex approach as this one is justified in this highly symptomatic patient group.

Angina Pectoris↗
PubMed1997

[Incidence and therapy of peripheral arterial vascular complications after heart catheter examinations].

We analyzed the incidence and management of major vascular complications at the arterial puncture site following diagnostic or interventional cardiac catheterization. 27387 cardiac catheterization procedures were performed for diagnostic (n = 19581) or interventional (n = 7806) purposes at our institution during a 7-year study period. A total number of 114 major vascular complications (0.42%) were identified. In 36 (0.13%) patients an arterial occlusion at the puncture site was detected, 34 patients (0.12%) had severe hematoma (blood transfusion or surgical repair necessary), 32 patients (0.12%) developed false aneurysms, 9 patients (0.03%) with av-fistulas and 3 patients (0.01%) had other complications. The following factors were predictive for a significant increase in the incidence of major vascular complications: Female gender, interventional catheterization using larger introducer sheaths and necessitating effective perioperative doses of heparine, and peripheral vascular disease. Operative repair was necessary in 62 patients (54%), 34 patients (30%) were treated conservatively. In 18 patients (17%) acute vascular occlusion could be managed by percutaneous transluminal balloon dilatation and intravascular thrombolysis of the obstruction, in 3 patients additional stent-implantation was necessary in the presence of a large occlusive dissection. Overall the rate of clinically significant major vascular complications is low. In the future a greater number of vascular complications at the entry site for cardiac catheterization will be treated with nonoperative methods (e.g. manual compression of pseudoaneurysms or catheter-based techniques for recanalization of acutely occluded vessels.

Adult↗
PubMed1997

[Rate of restenosis after PTCA in patients with terminal renal failure. A quantitative coronary angiography study].

Patients with end-stage renal disease (ESRD) have a high incidence of coronary artery disease. In 30-60% of these patients coronary artery disease can be demonstrated by coronary angiography often prompting myocardial revascularization. Previous studies on PTCA in patients with ESRD have suggested a high rate of procedural complications and restenosis. We studied the rate of restenosis after PTCA in 23 patients with chronic renal failure (17 males, 6 females, age: 52.5 +/- 18.3 years). After primarily successful PTCA all patients were restudied angiographically within 6-12 months. Using quantitative coronary angiography 13 patients (56%) demonstrated restenosis (stenosis > 50% luminal diameter). In 11 of these patients further revascularization therapy was indicated (6 x PTCA, 5 x CABG). Before follow-up angiography 12 patients demonstrated recurrence of angina pectoris, the sensitivity of clinical symptoms for angiographic restenosis was 69%. High concentrations of triglycerides (265 +/- 160 mg/dl), total cholesterol (258 +/- 53 mg/dl) with low HDL-levels (34 +/- 14 mg/dl) as well as elevated plasma levels of fibrinogen (481 +/- 114 mg/dl) were measured before PTCA. The mechanisms contributing to the high rate of coronary restenosis in patients with ESRD remain unclear, influence of lipid abnormalities, hemostatic factors and fibrinolytic state as well as primarily uremic factors have to be discussed. Prospective interventional studies are needed to address the relevance of PTCA for myocardial revascularization in this patient group.

Adult↗
PubMed1997

[Intracoronary dipyridamole reduces the incidence of acute coronary vessel occlusion in percutaneous transluminal coronary angioplasty--a prospective randomized study].

Even in the era of coronary stenting, acute coronary artery occlusion continues to represent a significant limitation of percutaneous transluminal coronary angioplasty (PTCA). Despite application of heparin and aspirin, abrupt vessel closure still occurs in 2-8%, depending on the definition applied. Especially patients receiving PTCA for acute coronary syndromes are at high risk for abrupt vessel closure. The formation of an intracoronary thrombus plays a central role in the pathogenesis of abrupt vessel closure. Dipyridamole induces dilatation of coronary arteries and prevents platelet aggregation by a mechanism that differs from that of aspirin. The primary purpose of the study was to evaluate whether adjunctive local intracoronary therapy with dipyridamole could reduce the incidence of coronary artery occlusion following PTCA. Secondary endpoints were defined as myocardial infarction, necessity for bypass grafting, and death. In 939 PTCA procedures performed for stable angina and in 155 angioplasty procedures for acute coronary syndromes (unstable angina, acute myocardial infarction), patients were randomized to receive conventional pretreatment consisting of heparin 15,000 I.E. and aspirin 500 mg i.v. or additional intracoronary infusion of dipyridamole (0.5 mg/kg body weight). Dipyridamole was applied in 550 interventions (455 interventions in men, 95 interventions in women, age = 59.2 +/- 8.4; 74 emergency procedures); conventional pretreatment was performed in 544 interventions (444 interventions in men, 100 interventions in women, age 58.3 +/- 7.9; 81 emergency procedures). Intracoronary application of dipyridamole resulted in a significant reduction in the incidence of abrupt vessel closure following PTCA. This significant reduction was observed in patients presenting with stable ischemia as well as in patients receiving PTCA for acute coronary syndromes. Concerning secondary end points, intracoronary application of dipyridamole did not affect the need for bypass grafting or the incidence of death following PTCA. Intracoronary application of dipyridamole was associated with a reduction in the incidence of myocardial infarction following PTCA which, however, failed to reach significance.

Adult↗
PubMed1997

Refractory angina pectoris in end-stage coronary artery disease: evolving therapeutic concepts.

Refractory angina pectoris in coronary artery disease is defined as the persistence of severe anginal symptoms despite maximal conventional antianginal combination therapy. Further, the option to use an invasive revascularization procedure such as percutaneous coronary balloon angioplasty or aortocoronary bypass grafting must be excluded on the basis of a recent coronary angiogram. This coronary syndrome, which represents end-stage coronary artery disease, is characterized by severe coronary insufficiency but only moderately impaired left ventricular function. Almost all patients demonstrated severe coronary triple-vessel disease with diffuse coronary atherosclerosis, had had one or more myocardial infarctions, and had undergone aortocoronary bypass grafting (70% of cases). We present three new approaches with antiischemic properties: long-term intermittent urokinase therapy, transcutaneous and spinal cord electrical nerve stimulation, and transmyocardial laser revascularization.

Aged↗
PubMed1997

Relevance of conventional cardiovascular risk factors for the prediction of coronary artery disease in diabetic patients on renal replacement therapy.

BACKGROUND: Diabetic patients undergoing renal replacement therapy have a high cardiovascular mortality. As the rate of patients with diabetic nephropathy rises, adequate risk stratification subsequent to renal transplantation is warranted. It was the aim of our study to elucidate whether conventional risk factors are valid predictors of coronary artery disease in this group of patients with chronic renal failure subsequent to transplantation. METHODS AND RESULTS: Between 1989 and 1993, 105 consecutive diabetic patients (70 men, 35 women, 77 type I and 28 type II diabetics, mean age 43 +/- 12 years) were examined during the first six months of dialysis treatment. Coronary angiography was performed in all patients regardless of clinical symptoms of coronary artery disease (CAD). In 38 patients (36%) CAD was documented (single-vessel disease: 17 patients, double-vessel disease: 6 patients, triple-vessel disease: 15 patients). Manifestations of coronary atherosclerosis were seen in 49 patients (47%). Angina pectoris was present in 9 out of 38 patients (24%), the sensitivity to detect CAD was 43% and 52% for ST-segment depression assessed at rest. Risk factors for atherosclerosis like hypertension, smoking, cholesterol (total cholesterol, HDL-,LDL-cholesterol), triglycerides as well as concentrations of lipoprotein (a) and fibrinogen were not significantly different in patients with or without coronary artery disease. Atherosclerotic manifestations of cerebral and peripheral arteries as well as manifestations of diabetic microangiopathy like retinopathy did not correlate with the prevalence of CAD. In 11 out of 38 patients (29%) cardiac interventions (3 x CA BG, 8 x PTCA) were performed. All of them were defined as transplantable after myocardial revascularisation. CONCLUSIONS: Clinical symptoms as well as the cardiovascular risk profile are not valid predictors of CAD in diabetic patients with chronic renal failure. Therefore coronary angiography should be performed in all diabetic patients prior to renal transplantation.

Adult↗
PubMed1997

Antithrombotic treatment in stable coronary syndromes: long-term intermittent urokinase therapy in end-stage coronary artery disease and refractory angina pectoris.

Interventions that modify lipid metabolism and blood coagulation have been shown to favourably influence the natural course of coronary artery disease in terms of the primary prevention and treatment of acute cardiovascular events. Various findings suggest that such interventions may also preserve and enhance myocardial perfusion in the chronic stage of the disease. Long-term intermittent urokinase therapy was developed for patients with end-stage coronary artery disease and refractory angina pectoris. A dose of 500,000 IU of urokinase given intravenously as a bolus three times a week for of 12 weeks reduced symptoms by 70% and was accompanied by objective improvements in myocardial perfusion and an increase of ergometric exercise capacity. The possible therapeutic mechanisms of long-term intermittent urokinase therapy-improvement of rheological blood properties mediated by fibrinogen reduction, thrombolysis of non-occlusive subclinical thrombi, and regression of atherosclerotic plaques-are discussed in the context of other antithrombotic approaches.

Angina Pectoris↗
PubMed1997

Restenosis after elective coronary balloon angioplasty in patients with end stage renal disease: a case-control study using quantitative coronary angiography.

OBJECTIVE: To assess the rate of angiographic restenosis in patients with end stage renal disease after elective coronary angioplasty. DESIGN: A retrospective case-control study of 20 patients with end stage renal disease and 20 sex and age matched controls without renal disease, who had undergone primarily successful coronary angioplasty. Control coronary angiography was performed regardless of worsening or renewed incidence of anginal symptoms. MAIN OUTCOME MEASURES: Group comparison of coronary morphology, as evaluated by quantitative coronary angiography, and of cardiovascular risk factors. RESULTS: The rate of angiographic restenosis was 60% in patients with renal disease and 35% in controls. In patients with end stage renal disease the following differences (mean (SD) were found versus controls: raised plasma fibrinogen (483 (101) v 326 (62) mg/dl, p < 0.001); raised plasma triglyceride (269 (163) v 207 (176) mg/dl, p < 0.01); smaller diameter of the coronary reference segment (2.59 (0.87) v 2.90 (0.55) mm, p < 0.10); smaller minimum luminal diameter of the dilated stenosis (0.77 (0.46) v 0.97 (0.27) mm, p < 0.05). Discriminant analysis showed that minimum luminal diameter before angioplasty (r = -0.79) and fibrinogen (r = +0.34) had the highest statistical association with restenosis. CONCLUSIONS: The high rate of angiographic restenosis in patients with end stage renal disease seems to be related to the size of the vessel dilated and to an increased prothrombotic risk, as indicated by higher fibrinogen concentrations.

Angioplasty, Balloon, Coronary↗
PubMed1997

[Significance of coronary thrombosis for chronic myocardial ischemia].

Apart from the relevance of disorders of lipid metabolism for the clinical and morphological progression of coronary artery disease, coronary thrombosis has received increasing attention in recent years. It is undoubtedly the decisive factor in the pathogenesis of acute coronary syndromes, which is underlined by the therapeutic success of various antithrombotic interventions. Furthermore coronary thrombosis is regarded to be a key factor for morphological disease progression also in stable coronary syndromes, which eventually may lead to critical limitation of myocardial perfusion. This is caused by the formation of subclinical coronary thrombi, which either undergo endogenous lysis or become morphologically fixed as they are incorporated into the plaque. Besides local factors, systemic disturbances of hemostasis and endogenous thrombolysis are of relevance. The concept of thrombotic progression of coronary thrombosis is supported by data on the reduction of morphological disease progression or antiischemic effectiveness of anti-thrombotic interventions like aspirin, low-molecular weight heparin and low-dose intermittent urokinase therapy. Percutaneous transluminal coronary angioplasty results in deep mechanical injury of the vessel wall, which is accompanied by secondary coronary thrombosis in the majority of the cases, not necessarily leading to abrupt vessel closure. Particularly, dilatation of primary thrombus as it has been described as the substrate of the culprit lesion in unstable coronary syndromes, promotes release of thrombin and activation of platelets, which in turn furthers the proliferative processes in the pathogenesis of restenosis. Even though data on the reduction of the rate of restenosis by the use of platelet aggregation inhibitors like aspirin, ticlopidin and dipyridamole have not consistently supported this concept, the EPIC. Study has shown that even in patients with stable angina pectoris clinical restenosis rate may be reduced by a platelet-IIb/IIIa-antagonist.

Angina Pectoris↗