Biomedical subjects
Publications and source records attributed to R Verhaeghe.
We report a patient in the "atherosclerotic age" with symptomatic fibromuscular hyperplasia of both external iliac arteries. Our patient had a history of bilateral intermittent claudication secondary to a concentric narrowing of a long segment of both external iliac arteries. A typical associated involvement of both internal carotid arteries was present.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Five patients with a "blue or purple" toe syndrome due to atheromatous embolization probably precipitated by oral anticoagulant therapy are reported. In four, the symptoms started a few weeks after initiation of oral anticoagulants and in the fifth they were clearly aggravated by coumarinic drugs. Prior to anticoagulation, one patient had received a course of thrombolytic therapy and two had undergone an arterial catherization without embolic events. A diagnostic arteriography performed in four patients caused no new symptoms. All patients had advanced atherosclerosis. A shaggy aorta and/or pelvic arteries were found in four and in the fifth a highly stenotic femoral lesion appeared the source of peripheral embolization. Oral anticoagulants were interrupted in all five and four underwent reconstructive vascular surgery to eradicate the nidus of atheromatous emboli. One died postoperatively from multiple organ failure. The poor condition of the fifth patient precluded aorto-iliac surgery. No new episodes of embolization occurred and the symptoms disappeared, although one patient needed a toe amputation for a skin lesion that had proceeded to gangrene. The possible role of anticoagulant drugs in precipitating atheromatous embolization is discussed and the importance of recognizing the syndrome is emphasized.
This study reports the results and complications of local thrombolytic therapy of 50 recently occluded grafts. These occurred in 41 patients with acute severe but still reversible ischemia. The majority were infra-inguinal synthetic grafts. Thrombolysis was induced with urokinase (n = 1), streptokinase (n = 11) or alteplase (n = 38) via an intra-arterial catheter. Complete angiographical lysis was obtained in 36 grafts (72%) and partial lysis in 6 (12%). The highest lysis rate was obtained with alteplase (32/36; 89%). Complementary endovascular and/or surgical intervention was needed in 17 patients to correct an underlying stenosis and/or to save the limb. Fifteen complications occurred (30%) of which distal embolization (n = 4) and bleeding (n = 8 of which 3 fatal) were the most frequent. Six of the bleeding episodes occurred in patients on chronic aspirin intake. The late results were poor. At six months, the primary patency of successfully lysed grafts dropped to 19% and the limb salvage rate to 64%. Thrombolytic therapy is far from the ideal management of thrombosed grafts: maintenance of restored patency is the challenge.
We prospectively studied 41 consecutive elderly patients with serum cobalamin (vitamin B12) levels lower than 125 pmol/l. The protein-bound cobalamin absorption test (PBAT) was performed in 34 of them and in 27 selected elderly control patients. The lower decision limit was 0.18% and an abnormal test was detected in only 9 (26%) of the 34 patients with low serum cobalamin level. When the PBAT was compared to the Schilling (Dicopac method) test, a concordant result was found in 80%. Serum methylmalonic acid and/or total homocysteine concentrations were elevated in 75% (26/35) of the patients with low serum cobalamin levels but also in 30% (5/17) of the control patients. Of the 12 and 9 cobalamin-deficient patients with elevated serum levels of methylmalonic acid and homocysteine, normalization after cobalamin therapy was obtained in 11 and 5 respectively. In conclusion, determination of serum metabolites and their response to cobalamin therapy are a sensitive index of significant cobalamin deficiency and a useful means of distinguishing between cobalamin and folate deficiency. The PBAT offers little advantage over the Schilling test in diagnosing cobalamin malabsorption in elderly patients.
This review discusses the problem of deep vein thrombosis (DVT) after operation and identifies three levels of risk of DVT: low (less than 10 per cent), moderate (10-40 per cent) and high (40-80 per cent). Special emphasis is placed on the most recent prophylactic treatment, low molecular weight heparins (LMWHs), particularly enoxaparin. Several LMWHs are now available, but they differ slightly and each must be evaluated on its own merits. In general, however, LMWHs are both effective and safe in those patients at moderate or high risk of DVT. Thromboprophylaxis is cost effective when analysed using health-economic methodology.
Of 732 consecutive patients admitted to an acute geriatric ward, 178 (24%) were found to be anaemic (haemoglobin of 115 g/l or below). An appropriate cause responsible for anaemia was identified in 83%. The anaemia of chronic disorders (ACD) (35%) and iron deficiency anaemia (15%) were the commonest causes. The spectrum of disorders associated with ACD is much broader than the classical category of infectious, inflammatory and malignant disorders. The relatively high prevalence of the myelodysplastic syndrome (5%) is striking and this syndrome as a cause of anaemia in geriatric patients deserves more attention than it has so far received. No obvious cause was found in 17%. The clinical significance of this finding remains unclear.
Sixty patients in whom a prosthetic aorto-femoral bypass graft was inserted were pretreated with ticlopidine (250 mg b.i.d.) or placebo in a double-blind study. Blood loss and transfusion need were higher in ticlopidine treated patients. Platelet survival was partially corrected and platelet deposition on prosthetic surfaces was inhibited with ticlopidine. The study suggests that ticlopidine does not increase excessively the bleeding risk during peripheral vascular surgery and that the antiplatelet drug may have beneficial effects in the early phase after insertion of prosthetic vascular graft.
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In a 4-year period, 17 patients were diagnosed as having bilateral carotid artery obstruction on ultrasonic duplex examination. Twelve had been referred because of recent neurological symptoms and the remaining 5 during cardiac or peripheral vascular work-up. Three patients had a completely silent occlusion of their two carotid arteries. Cardiac and/or peripheral vascular symptoms were present in 11 subjects. Mean follow-up was 28 months. No further strokes occurred. The 3-year cumulative stroke-free survival by life-table analysis was 75%. Myocardial infarction was the cause of death in 2 of 4 patients. For some patients with bilateral carotid artery occlusion, the clinical outcome is better than anticipated.
Prophylactic therapy with antiplatelet drugs aims to improve both the general prognosis of patients and the local progression of peripheral arterial disease. A recent meta-analysis of 28 trials revealed that the proportional risk reduction in serious vascular events is similar to that in cardio- and cerebrovascular disease. A decreased incidence of vascular complications was also found in a meta-analysis of 4 trials with ticlopidine, and a recent Swedish study [Swedish Ticlopidine Multicentre Study (STIMS)] confirmed that long term ticlopidine reduces both mortality and cardio- and cerebrovascular morbidity. There is also evidence that aspirin (acetylsalicylic acid) and ticlopidine retard progression of atherosclerosis and the occurrence of its thrombotic complications, in patients with arterial disease of the legs. Meta-analysis has recently indicated that antiplatelet agents reduce the incidence of graft occlusion in arterial surgery. These drugs are also traditionally prescribed after percutaneous revascularisation procedures. The efficacy of antiplatelet therapy in patients with peripheral arterial disease emphasises the role of platelets in this condition.
The combination of thromboxane synthase inhibition with thromboxane receptor antagonism has been shown to result in a strong inhibition of platelet aggregation and a prolongation of the bleeding time (Gresele et al., J. Clin Invest 1987; 80: 1435-45). Ridogrel is a single molecule that efficiently achieves both inhibitions in human volunteers. The present study was performed in patients with obstructive peripheral arterial disease and elevated plasma beta-thromboglobulin levels. Patients were treated with either 2 x 300 mg ridogrel or 2 x 300 mg placebo per day for 2 1/2 days, according to a double blind randomised parallel design. Plasma beta-thromboglobulin decreased significantly throughout active treatment starting within 2 h after administration; serum and urinary immunoreactive TxB2 levels and urinary 11-dehydro-TxB2 excretion were significantly lower and serum PGE2 and 6-keto-PGF1 alpha levels significantly higher with ridogrel; no changes were observed in the placebo-treated group. In conclusion this study demonstrates a reduction of platelet activation in vivo by ridogrel.
Protein C deficiency has been reported to be associated with a high risk for thromboembolism. We report three patients with protein C deficiency: one suffered from left renal vein thrombosis, another from recurrent venous thrombosis of the legs complicated by pulmonary embolism and the third from an extensive thrombosis of the splanchnic veins with partial Budd-Chiari syndrome. We discuss the unusual sites of venous thrombosis in protein C deficient patients, the factors which may act as thrombotic trigger and the strategy of long-term prevention.
Laser angioplasty with Sapphire Contact Probes coupled to a Nd:YAG laser followed by balloon angioplasty was performed in 30 patients with 26 femoropopliteal and 4 iliac artery occlusions. Mean length of the occlusions was 4.5 +/- 1.6 cm with a mean duration of occlusion of 7.06 +/- 6.18 months. Initial angiographic success was obtained in 25/30 (83%) procedures, including 3/4 successes in the iliac artery (75%) and 22/26 successes in the femoropopliteal artery (84%). Reason for failure was perforation in 2 patients, and subintimal passage of the probe in 2, and heavy calcification of the lesion in 1 patient. Early rethrombosis in 3 patients reduced the primary success rate to 73%. Peripheral emboli necessitating surgical intervention occurred in 2 patients. Of the 22 recanalized arteries 21 remained patent with a mean follow-up of 8.4 +/- 3.3 months. It remains to be determined whether the angiographic and clinical short and long term success rate of "laser assisted balloon angioplasty" will be greater than after thrombolysis or conventional balloon angioplasty.
Patients with symptoms of deep vein thrombosis for less than 10 days were treated with a standard dose of heparin. In the open label phase of the trial, 11 patients received 100 mg rt-PA on the first day and 50 mg on the subsequent day in an 8 hour infusion. In the double-blind phase, 8 patients were randomized to the same rt-PA regimen, 6 patients to an infusion of 50 mg rt-PA over 8 hours on days 1 and 2, and 7 patients to placebo infusions. The mean change in venographic score in all patients treated with rt-PA plus heparin is -3.8 units compared to -0.6 units in patients treated with heparin alone (p = 0.06). Bleeding complications classified as major were noted in 8/25 patients receiving the combined treatment.
A patient is reported who developed a marked prolongation of QTc and life threatening ventricular arrhythmias during oral Ketanserin therapy. No other factors contributing to the QTc prolongation or to the occurrence of ventricular arrhythmias were found. The relevant literature is reviewed.