Search

Safe and permanent closure of patent ductus arteriosus (PDA) can be accomplished with an ivalon plug introduced by catheterization from the femoral artery. The authors' experience thus far obtained from treating more than a hundred patients suggests that the technique described in this paper is a feasible alternative to the surgical approach. A prerequisite has been the size and shape of the PDA, the lumen of which had to be conical in shape and smaller than the lumen of the femoral artery. Now safe closure of oversized PDA complicated by pulmonary hypertension has become possible, using a plug designed with a special mechanism for anchorage to the PDA. The technique of this closure is described in detail in this report of its successful use in a 50-year-old woman patient with an oversized, calcified PDA complicated by pulmonary and systemic hypertension and cystic lung disease. Treating such high-risk cases with transfemoral closure means real improvement in therapy over surgical treatment.

Es werden die angiographischen Befunde in zwei Fallen von Aortenbogensyndrom auf entzundlicher Basis und bei einem Fall von arteriosklerotischer Obliteration beider Arteriae subclaviae ausfuhrlich dargestellt. Im Hinblick auf die heute prinzipiell mogliche Verbesserung der zerebralen Durchblutung durch gefaschirurgische Eingriffe wird auf die Bedeutung einer gezielten angiographischen Untersuchung der supraaortischen Aste zur exakten Ermittlung der verbliebenen Restzirkulation hingewiesen. Die Angiographie ist die einzige diagnostische Methode, die etwas uber die Operabilitat eines Aortenbogensyndroms aussagen und den Operationserfolg belegen kann. The angiographic findings in two cases of aortic arch syndrome of inflammatory origin are described together with a single case of arteriosclerotic obliteration of both subclavian arteries. In view of the possibility of improving the cerebral circulation by vascular surgery it is important to obtain selective angiographic demonstration of the supra-aortic vessels for an exact evaluation of the remaining circulation. Angiography is the only diagnostic method which can be used to assess operability in cases of the aortic arch syndrome and to prove the success of the operation. Les auteurs demontrent les angiographies de 2 cas de syndrome de la crosse de l'aorte d'origine inflammatoire et d'un cas d'une obliteration par arterio-sclerose des deux arteres sous-clavieres. En tenant compte de l'amelioration actuellement possible de la circulation cerebrale par des interventions chirurgicales sur les vaisseaux, les auteurs soulignent l'importance de l'examen angiographique dirige des branches de la crosse aortique afin de determiner exactement l'etat du reste du reseau vasculaire. L'angiographie est la seule methode de diagnostic qui permet de poser le pronostic de l'operabilite d'un syndrome de la crosse de l'aorte et de verifier le succes de l'operation. Se describen detalladamente los hallazgos angiograficos en dos casos de sindrome del cayado aortico de naturaleza inflamatoria y en un caso de obliteracion arteriosclerotica de ambas arterias subclavias. Teniendo en cuenta que actualmente es posible mejorar la vascularizacion cerebral por medio de intervenciones quirurgicas a nivel del sistema vascular del encefalo, se senala la importancia del examen angiografico selectivo de los troncos supraaorticos para la valoracion exacta de la circulacion residual presente. La angiografia es el unico procedimiento diagnostico que puede decir algo acerca de la operabilidad de un sindrome de arco aortico y que puede fundamentar el resultado quirurgico.

A new technique for the transvenous implantation of a specially designed atrial sensing electrode is described. In combination with a ventricular stimulating electrode and an atrial-controlled pacemaker, the method enables synchronization of atrial with ventricular activity. The atrial sensing electrode is put into the right atrial appendage through a preshaped radiopaque Teflon applicator catheter. Two hooks on the electrode tip provide for safe and secure anchoring of the electrode tip to trabeculae of the atrial appendage. The technique has been used for synchronous P wave pacing in 12 patients with complete atrioventricular block, most of them suffering from AdamStokes attacks. Three additional patients with sinoatrial block were treated by means of anchored atrial electrodes. Observation periods of up to 39 months showed no dislocation of any of the anchored atrial electrodes, and performance in all patients was faultless.

The only effective causal therapy in thromboses of the deep pelvic and femoral veins is fibrinolysis or operative thrombectomy. Concerning the contraindications, fibrinolysis is successful only up to the 5th day. After that time patients with deep vein thrombosis were submitted to thrombectomy and at the same time, to prevent renewed thrombosis secondary to a slowing down of the flow, a peripheral arteriovenous fistula was temporarily positioned. Between 1974 and 1976, 14 patients were treated operatively this way. In 6 cases of pulmonary embolism a vena cava umbrella filter was inserted.

30 patients underwent implantation of the Mobin-Uppin filter for recurrent life threatening pulmonary embolism. 20 patients could be followed by phlebography. In 11 cases obstruction of the inferior vena cava was observed. Due to the collaterals having developed in the intermediate time there were no significant clinical symptoms below the obstruction.

In 53 external patients with extensive malignant renal tumours before nephrectomy the renal artery was closed centrally by radioopaque ivalonchips. 46 arteries were completely obturated, in 7 cases the embolization was incomplete. This method of embolization is indicated preoperatively because there are some advantages concerning technique of operation. In or ivalon-material there was only one complication without clinical symptoms. The occurring ischemic pain was controllable by medicaments and eased off within some hours. Directly after transcatheter occlusion the patients can be transported back under first aid conditions in hospital where will be nephrectomy carried out.

In 48 patients with angiographically ascertained coronary arteriosclerosis and 15 patients with unconspicuous cardiac findings a complete pressure-flow-volume-analysis of the left ventricle in rest and under artificial atrial tachycardia (atrial pacing) was carried out. In 26 patients with coronary arteriosclerosis a typical angina pectoris could be induced, however, in this group a specific constellation of the findings of the initial values was not present. Under influence of angina pectoris an increase of the disturbances of the regional contraction, connected with a significant decrease of the ejection fraction and of the isovolumetric contractibility parameter Vpm. Apart from this a significant increase of the enddiastolic ventricular pressure and of the quotient deltaP/deltaV in the diastole as a sequel of a decreased distensibility of the ventricle was found. In one part of the patients as an expression of the efficacy of the Frank-Starling-mechanism also the enddiastolic volume increased. Altogether a broad spectre of the functional changes was the result, the direction and degree of severity of which could not be foreseen according to the adequate findings in rest.

Percutaneous transluminal angioplasty (PTA) is intimately linked with the name of CT Dotter [1]. In the late 1960s we introduced with good results our caged balloon (to treat occlusions of pelvic and lower extremity arteries) [5]. The development of newer types of catheter by Dr. Gruntzig has resulted in a major breakthrough and the present significance of PTA [3]. He was the first to dilate a coronary stenosis successfully [2]. Although more than a thousand patients worldwide have so far been treated by percutaneous transluminal coronary angioplasty (PTCA), it is still a method that must be used with great caution if it is not going to fall into disrepute [4,6]. Only a prolonged period of objective analysis of all results will allow us do define more clearly its indications and contraindications. During the last 2 1/2 years we have applied PTCA only 40 times. We have selected patients who would otherwise have had to undergo bypass procedures.

In 30 patients with postinfarction condition (11 infarctions of the posterior wall, 11 infarction of the anterior wall, 8 aneurysms of the anterior wall) the regional contraction of the left ventricle was analysed by 3 different metrical methods (semiaxis, surface and angular method) on the basis of the kineventriculogramme in the 1st oblique diameter. With all 3 methods a significant reduction of the mean contraction amplitude could be proved in the affected ventricular region. Using the semiaxis method, in all 30 patients an asynergy could be identified. By the surface method 2 patients with infarction of the posterior wall and 1 patient with infarction of the anterior wall, by the angular method 3 patients with infarction of the posterior wall and 1 patient with infarction of the anterior wall were not established. According to the disturbance of the entire function of the ventricle the number of the segment with disturbed contraction was largest in the group with aneurysm of the anterior wall and smallest in the group with infarction of the posterior wall. Even here the semiaxis method showed the greatest and the angular method the smallest sensitivity.

Of the X-ray methods for the demonstration of disturbances of the blood supply only the angiography is of practical importance. The proof of vascular calcium on so-called X-ray pictures of the soft parts informs about wall processes, but says absolutely nothing about a disturbed flow. The diagnosis of an obliterating vascular disease is still successful on the extremities with the help of the simple clinical means of pulse palpation, auscultation, measuring of the blood pressure with comparison of the sides, particularly when load methods are included. But the angiography is the only diagnostic method which makes recognizable localisation, extension and degree of obliterating changes intra vitam. Nevertheless it stands at the end of a diagnostic chain and, as far as the ischaemia of the extremities is concerned, it is absolutely indicated only as preoperative method. The development of newer therapeutic methods by means of the saving catheter technique for the restoration of the vascular system is described in short and outlined in its tendencies.

Patent ductus arteriosus was the first inborn cardiac defect ever eliminated by percutaneous transvascular therapy. The method, results, and complications of Ivalon plugging of the ductus in 208 patients between 5 and 62 years old and treated between 1967 and 1985 are described. Permanent closure was accomplished in 197 patients (94.7%). The following particular benefits are obtainable from the method: no need for thoracotomy; local anesthesia applicable to 65% of all cases; 30 mm average time of intervention; only moderate invasiveness to the patients; only 7 days of hospitalization; good cost-benefit ratio.

384 patients with ischaemic heart disease were treated surgically. Out of 165 patients operated upon consecutively, in 38 (23%) an intramural course of coronary arteries was found. Peroperative diagnosis of the intramural course of the anterior interventricular branch is feasible with a high probability; diagnostic criteria were also elaborated for the intramural course of the marginal branch. Several aspects of the operation technique and tactics are discussed.

Transluminal angioplasty was carried out in a series of 100 consecutive patients with ischemic disease of the legs. One hundred twenty-one procedures were done with initial success in 76% and long-term success (more than 2–7 years) in 37–40%. Benefits obtained from angioplasty were assayed clinically in all and by follow-up arteriography in 35 patients. Angioplasty was found to be most successful in patients over 40 with short segmental occlusive disease limited to the superficial femoral artery. Maintenance anticoagulant therapy appeared to improve the chances for lasting patency. In properly chosen patients, transluminal angioplasty should be considered the primary treatment for vascular occlusive disease in the legs.

In 15 patients with extensive malignant renal tumours before operation the artery of the kidney concerned was closed by foam substance particles (ivalon) after percutaneous selective catheterisation. The occurring ischaemic pain was controllable by medicaments and eased off after hours. In most cases the nephrectomy followed on the same day, but it can be performed also on the following day. The operation was principally performed from the transverse flank cut in practically bloodless kidney. Compared with the major interventions (transthoraco-abdominal or transabdominal) of the tumour nephrectomy the procedure described in this paper as a more careful one which at the same time meets the principles of modern surgery of cancer and which can also suggested to patients suffering from a severe disease.

The delimitation of regional disturbances of contraction of the left ventricle (asynergies) demands knowledge of the behaviour of the contraction of the normal left ventricle. For the exact recognition of asynergies and for scientific inquiries in these cases the use of objective metrical methods is necessary. Therefore, in 14 patients without organic heart disease the behaviour of the regional contraction of the left ventricle was determined on the basis of the cineventriculography according to three different metrical methods (semiaxis, surface and angular method). For all 3 methods in the first oblique projection of 30 degree a larger mean amplitude of the contraction of the anterior wall was the result in contrast to the posterior wall. Consequently, different borderline regions for the anterior wall and the posterior wall must be established for the delimination of asynergies.