PURPOSE: Iliac vein compression syndrome (IVCS), first characterized by Cockett and Thomas in 1965, is the development of iliofemoral deep venous thrombosis due to compression of the left common iliac vein against the spine and pelvic brim by the right common iliac artery. Thrombectomy treatment of the underlying compression is essential if significant long-term sequelae are to be avoided. Surgical treatment options include venous reconstruction or venous bypass, but treatment using endovascular techniques have recently been described. This study was conducted to evaluate the usability of endovascular treatment (esp. thrombolysis with stent insertion) in a venous outflow obstruction resulting from IVCS. METHOD: During a 2-year period, 20 patients (17 women, 3 men; mean age, 60 years) presented with clinical and imaging findings consistent with IVCS. All patients presented with leg edema or pain. The mean duration of symptom onset was 6.6+/-4.4 days, ranging from 1 to 15 days. All patients were evaluated using a Duplex scan, computerized tomography and venography. After the ascending venography had been performed, an infusion catheter system was placed, and urokinase infused locally into the thrombus burden. After near complete clot dissolution, the residual left common iliac vein stenosis was treated by means of angioplasty and the placement of a Wallstent. All patients continued to receive oral warfarin. Patients were followed-up by means of clinical visits, and the stent patency was assessed by means of a Duplex scan or computerized tomography. RESULT: The total dose of urokinase used and the duration of infusion were 2.28+/-0.93 million unit, ranging from 1.00 to 5.20 and 46.8+/-14.8 hours, ranging from 14 to 72 hours, respectively. Grade III (complete lysis) thrombolysis was achieved in 17 patients. All 17 patients successfully received a Wallstent. The initial clinical success was 100%, with complete resolution of symptoms in all patients. One patient, with combined ovarian cancer, had a recurrent symptomatic deep vein thrombosis and complete occlusion of the stent due to thrombosis 2 months after treatment. However, no other patients showed evidence of deep vein thrombosis after treatment. The overall patency rate of the stenting at 18 months was 94.1%. There were no deaths, pulmonary embolism, cerebral hemorrhage or major bleeding complications. CONCLUSION: These results suggested that the treatment of iliac vein compression syndrome, using catheter directed thrombolytic therapy and venous stent insertion, was a safe and effective method at the mid term evaluation. These patients will continue to be followed up with screening tests to further define the long-term patency.
Angioplasty ; Catheters ; Cerebral Hemorrhage ; Constriction, Pathologic ; Edema ; Endovascular Procedures ; Female ; Hemorrhage ; Humans ; Iliac Artery ; Iliac Vein* ; Leg ; Male ; Mass Screening ; May-Thurner Syndrome* ; Ovarian Neoplasms ; Phlebography ; Pulmonary Embolism ; Spine ; Stents ; Thrombectomy ; Thrombolytic Therapy ; Thrombosis ; Urokinase-Type Plasminogen Activator ; Venous Thrombosis ; Warfarin

While endovascular aneurysm repair (EVAR) is prevailing for the treatment of abdominal aortic aneurysm (AAA) in modern vascular practice, PURPOSE: we conducted nationwide questionnaire survey to investigate the current status of AAA treatment and their results in Korea. METHOD: We reviewed the replies from 28 hospitals (33 departments) to the questionnaire inquiring annual number, clinical features, mode of treatment and results of AAA patients during the period from Jan. 2000 to Jul. 2004. Results: 980 AAA patients were reported including 292 ruptured AAA (29.8%) and 688 non-ruptured AAA (70.2%). For treatment of AAA, 834 (85.1%) surgical repairs (SRs) and 111 (11.3%) endovascualr aneurysm repairs (EVARs) were performed while 35 patients (3.6%) died of AAA rupture before operation. The locations of AAA were infrarenal in 889 (90.7%), juxtarenal in 62 (6.3%), and suprarenal in 29 patients (3.0%). Among 834 patients undergoing SR, 577 patients (69.2%) had non-ruptured AAAs and 257 patients (30.8%) had ruptured AAAs. Mean operative mortality rate was 4.1% after elective SRs, 30.7% after SR for ruptured AAAs, and 2.3% after EVARs. The reported brand name of stent graft devices were various including domestic custom-made in 56 (50.5%), imported brand in 18 (16.2%) while 37 (33.3%) stent grafts were not reported their brand name. The frequencies of type I and III endoleaks after EVAR were reported 5.8% and 5.8% respectively in 86 patients with an available data. CONCLUSION: SR has been used as a major treatment option in Korea for the treatment of AAA patients while EVAR is increasing. The mortality rate of SR of AAA was comparable to western multi-center trial reports but mortality or morbidity rates of EVAR were unable to know in this questionnaire survey.
Aneurysm ; Aortic Aneurysm ; Aortic Aneurysm, Abdominal* ; Blood Vessel Prosthesis ; Endoleak ; Humans ; Korea* ; Mortality ; Questionnaires* ; Rupture ; Treatment Outcome

PURPOSE: Thrombus formation enhances both neointima formation and clinical restenosis after vascular injury or angioplasty. Thrombotic occlusions and intimal hyperplasia limit the success of vascular reconstructive procedures. Thrombolysis is expected to improve the outcome for both restenosis and acute arterial occlusion after injury. Tissue-type plasminogen activator (tPA) is commonly used clinically, and it is thought to play a critical role in vascular remodeling by mediating intravascular clot lysis and modulating cell migration within the vessel wall. However, there is controversy about the late effects of tPA on the vascular lumen either for preventing or enhancing intima hyperplasia in vivo. Thus, this study was done to evaluate the impact of a clinical infusion of tPA on the neointima formation after a balloon injury. METHOD: Forty male Sprague- Dawley rats weighting of 250~300 gm each were underwent aortic intimal denuation with a 2F balloon catheter. The rats were divided into two groups: the control group (n=20: normal saline infusion), and the*ean IMAR on the 21st day was 1.14+/-0.16 in the control group and 1.10+/-0.11 in the experiment group. The mean IMAR was lower in the experiment group, but the result was not statistically significant. In comparison to the gelatinolytic activity of MMP-9 and, activated MMP-2, there was no significant difference between the two groups. CONCLUSION: These results suggest that the effect of tPA on intimal hyperplasia after balloon injury to rat aorta showed minimal significance.
Angioplasty ; Animals ; Aorta* ; Catheters ; Cell Movement ; Humans ; Hyperplasia* ; Male ; Negotiating ; Neointima ; Rats* ; Thrombosis ; Tissue Plasminogen Activator* ; Vascular System Injuries

PURPOSE: This study was designed to determine the clinical factors affecting the long-term graft patency of leg arterial bypass for the patients with chronic lower limb arterial occlusion. METHOD: The clinical data of 81 femoro-distal bypasses performed at Yeungnam University Hospital from January 1996 to December 2002 were included for this retrospective study. A Log-Rank test of Kaplan-Meier method and Cox proportional hazard analysis were performed to identify those main effects that were predictive of graft patency. The patients, 79 males and 2 females, ranged from 37 to 81 years of age, with a mean age of 64. The highest incidence occurred among those in their 60s and 70s. Associated diseases were hypertension in 42 cases (51.8%), diabetes mellitus in 15 (18.8%), cardiac disease in 26 (32.1%) and cerebrovascular disease in 6 (7.4%). A history of smoking was noted in 76.5% of the cases. As for the clinical grades of chronic limb ischemia according to SVS/ISCVS classification, 21 limbs (25.9%) were classified as grade I (category 3), 40 (49.4%) as grade II, and 20 (24.7%) as grade III. The site of distal anastomosis was above the knee popliteal artery in 53 limbs (65.4%), below the knee popliteal artery in 8 (9.9%) and tibial artery in 20 (24.7%). As bypass conduit, autologous vein graft was used in 67 limbs (82.7%) and polytetrafluoroethylene (PTFE) graft in 14 (17.3%). There were no hospital mortalities or major perioperative complications. RESULT: From the univariate analysis of 21 clinical variables (age, sex, smoking, hypertension, diabetes mellitus, coronary arterial disease, congestive heart failure, chronic pulmonary disease, cerebrovascular disease, malignancy, hypercholesterolemia, clinical grade of chronic limb ischemia by SVS/ISCVS, level of occlusion, preoperative ankle-brachial index, type of graft, site of distal anastomosis, operation time, status of inflow artery, postoperative ankle-brachial index, clinical outcome criteria by SVS/ISCVS, postoperative anticoagulation therapy), 5 factors were identified as being associated with long-term graft patency: preoperative clinical grade (P=0.03), preoperative ankle-brachial index (P=0.00), level of occlusion (P=0.03), type of graft (P=0.00) and clinical outcome criteria (P=0.00). In multivariate analysis, type of graft, PTFE graft (vs. autologous vein graft, P=0.002), and clinical outcome criteria, minimally improved (vs. moderately, and markedly improved, P=0.029), showed a lower graft patency rate. CONCLUSION: These results suggest that autogenous vein is more acceptable for leg arterial bypass and poor early clinical outcome predicts poor long term graft patency rate.
Ankle Brachial Index ; Arteries ; Classification ; Diabetes Mellitus ; Extremities ; Female ; Heart Diseases ; Heart Failure ; Hospital Mortality ; Humans ; Hypercholesterolemia ; Hypertension ; Incidence ; Ischemia ; Knee ; Leg ; Lower Extremity ; Lung Diseases ; Male ; Multivariate Analysis ; Polytetrafluoroethylene ; Popliteal Artery ; Retrospective Studies ; Risk Factors ; Smoke ; Smoking ; Tibial Arteries ; Transplants* ; Vascular Patency ; Veins

PURPOSE: There is growing evidence that thrombosis and inflammation are closely interrelated and that the inflammatory response may play a role in the development of the syndrome of post-thrombotic, chronic venous insufficiency. A thrombus contains biologically active factors that stimulate cellular and structural alterations and lead to post-thrombotic venous abnormalities. Prolonged exposure to thrombus may result in the development of more severe pathologic conditions. To assess the effect of prolonged thrombus exposure on the development of secondary venous wall changes, the level of D-dimer test and the microscopic findings of thrombosed vein were analyzed in a rat venous thrombosis model. METHOD: The left iliac vein of male Sprague-Dawley rats weighing of 250 to 300 gm were thrombosed by means of either proximal ligation or temporary 24-hour occlusion with a microvascular clamp. The rats were divided into three groups: control group (n=10), thrombosis model by proximal ligation of the iliac vein only; group A (n=10), thrombosis model by proximal ligation of the iliac vein with treatment of low molecular weight heparin (LMWH; Clexane(r) 0.5 mg/kg, s.c.b.i.d); and group B (n=10), thrombosis model by temporary 24-hours clamp of the iliac vein without treatment of LMWH. The vein located 2 cm below from the initial ligation was harvested at time intervals of 7 and 14 days after ligation or clamp. Thrombi were identified by gross findings and indirectly quantitated with D-dimer test. RESULT: The levels of D-dimer test on days 7 and 14 after ligation or occlusion were significantly higher in the control group than in groups A and B (P<0.05). However, gross findings of intraluminal thrombosis were not present only in group B. These findings suggest that injection of LMWH did not prevent the development of thrombi around the ligation area. The neutrophilic infiltration of the perivascular area was evaluated microscopically (Hematoxylin-Eosin stain, x100). Severe perivascular neutrophilic infiltration was found in the control group and group A, whereas in group B neutrophilic infiltration was decreased to a mild or moderate degree. The vein wall thickness was evaluated by counting cells on representative sections through the mid vein area and by direct measuring of the vein wall usinga scale bar. The rat vein walls on days 7 and 14 were significantly thicker in the control group and group A than in group B (P<0.05). CONCLUSION: These results suggest that prolonged exposure of thrombus plays a major role in the development of secondary venous wall changes. However, the injection of LMWH did not prevent the development of secondary venous wall changes during the prolonged exposure of thrombus.
Animals ; Heparin, Low-Molecular-Weight ; Humans ; Iliac Vein ; Inflammation ; Ligation ; Male ; Neutrophils ; Rats* ; Rats, Sprague-Dawley ; Thrombosis* ; Veins ; Venous Insufficiency ; Venous Thrombosis*

PURPOSE: This study was undertaken to compare the activity of beta-Ig H3 (BigH3) and transforming growth factor (TGF)-beta on chondrogenesis by mesenchymal stem cells (MSCs). MATERIALS AND METHODS: MSCs in human bone marrow aspirated from 20 healthy donors were isolated by density gradient Ficoll-hypaque separation and expanded in culture. MSC-alginate beads were prepared and incubated for 28 days in the presence of 0.5 or 10 ng/mL of TGF-beta 1, TGF-beta 1+TGF-beta 3 or BigH3. Cellular viability, total collagen and glycosaminoglycan (GAG) contents were measured and compared. SPSS version 9.0 was used for the statistical analysis. RESULTS: TGF-beta 3 significantly enhanced cell viability in beads by day 21 (p=0.029). No significant differences were found in terms of cell viability (p=0.197) or in total GAG content (p=0.253) between 10 ng/mL of TGF-beta 1+3 and 10 ng/mL of BigH3. Total collagen content was higher in the BigH3 added group on day 21 (p=0.041). CONCLUSION: The replacement of BigH3 instead of TGF-beta produced appropriate external signals indicating the chondrogenic differentiation of human bone marrow MSCs.
Bone Marrow* ; Cell Survival ; Chondrogenesis* ; Collagen ; Humans* ; Mesenchymal Stromal Cells* ; Tissue Donors ; Transforming Growth Factor beta ; Transforming Growth Factors

PURPOSE: Migration and proliferation of vascular smooth muscle cells (VSMCs) are important for neointimal formation after arterial injury. Migration of VSMCs requires the degradation of basement membrane and extracellular matrix surrounding the cell. There is increasing evidence that VSMCs produce extracellular matrix-degradating proteinases, such as matrix metalloproteinases (MMPs) after arterial injury. METHOD: To assess the effect of gabexate mesylate, an MMP inhibitor, in VSMCs proliferation, migration and intimal thickening, the gelatinolytic activity of MMPs and the expression of VSMC alpha-actin mRNA were analyzed in the balloon-injured rat aorta model. Forty male Sprague-Dawley rats, weighing of 250 to 300 g, underwent aortic intimal denudation with a 2 F balloon catheter. The rats were divided into two groups: the control group (n=20: no medication), and the treatment group (n=20: daily intraperitoneal injection of gabexate mesylate (5.0 mg/kg)). The aorta was harvested at various time intervals, 1, 5, 7, and 21 days after the injury. MMP expression was analyzed by using gelatin zymography, the VSMC alpha-actin mRNA expression was analyzed by RT-PCR, and the intima to media area ratio (IMAR) were evaluated microscopically. RESULT: The treatment group showed significant suppression of intimal hyperplasia compared to the control group on day 21 (P<0.05). Mean IMAR on day 21 were 1.18+/-0.2 in the control group and 0.61+/-0.06 in the treatment group. The gelatinolytic activity of MMP-9 on day 1 after injury was significantly lower in the treatment group compared to the control group (P<0.05). The gelatinolytic activity of activated MMP-2 on days 5, 7, and 21 after injury, decreased significantly in the treatment group compared to the control group (P<0.05). The expression of VSMC alpha-actin mRNA increased on days 7 and 21 after injury. Although the expression of VSMC alpha-actin mRNA was lower in the treatment group, it was not statistically significant. CONCLUSION: These results suggest that gabexate mesylate suppresses intimal hyperplasia formation after arterial injury by decreasing activation of MMP.
Actins ; Animals ; Aorta ; Basement Membrane ; Catheters ; Extracellular Matrix ; Gabexate* ; Gelatin ; Humans ; Hyperplasia* ; Injections, Intraperitoneal ; Male ; Matrix Metalloproteinases ; Muscle, Smooth* ; Muscle, Smooth, Vascular ; Myocytes, Smooth Muscle* ; Peptide Hydrolases ; Rats ; Rats, Sprague-Dawley ; RNA, Messenger

PURPOSE: Despite recent progress in the procedures of revascularization, acute limb ischemia continues to account for a wide variety of complications, culminating very often in limb loss or death. These poor results after treatment of acute limb ischemia still remains a major challenge in vascular surgery. METHOD: To evaluate the clinical characteristics and risk factors for early limb loss in acute limb ischemia, the clinical data of 87 limbs (8 upper and 79 lower limbs) in 83 patients. that underwent revascularization for acute limb ischemia at Yeungnam University Hospital from January 1995 to February 2003 were analyzed retrospectively. A Log-Rank test of Kaplan-Meier method and Cox proportional hazard analysis were performed to identify those main effects predictive of amputation free survival. RESULT: The patients, 78 males and 9 females, ranged from 30 to 83 years of age, with a mean age of 67. The highest incidence occurred among people in their 50s and 60s. The underlying causes of acute limb ischemia were arterial embolism in 42 limbs (42/87, 48.2%), arterial thrombosis in 36 (36/87, 41.3%), bypass graft occlusion in 9 (9/87, 10.3%). The primary sources of embolism were cardiac origin in 25 cases (25/42, 59.5%), aneurysmal origin in 2 (2/42, 4.8%) and unknown origin in 15 (15/42, 35.7%). As for the severity of ischemia according to SVS/ISCVS classification, 40 limbs (40/87, 46.0%) were classified as category IIa, 39 (39/87, 44.8%) as category IIb, and 8 (8/87, 9.2%) as category III. For the treatment, 66 thromboembolectomies (including 20 cases treated with intraoperative thrombolytic therapy), 19 arterial bypasses and 2 catheter directed thrombolytic therapies were performed. There were 13 major amputations and 8 mortalities at 6 months after revascularization. Cumulative 15 day, and 1, 2, 4, and 6-month amputation-free survival rate of all survival patients were 88.8%, 85.7%, 83.9%, 83.9% and 81.4% respectively. Among the univariate analysis of 26 clinical variables, 10 factors were identified as being associated with amputation-free surviva: age (P=0.01), preoperative tissue gangrene (P=0.03), preoperative skin color change (P=0.00), preoperative muscle status (P=0.00), preoperative motor and sensory deficit (P=0.00, P=0.00), severity of ischemia by clinical category (P=0.00), symptom duration (P=0.02), length of occlusion (P=0.01), and cause of occlusion (P=0.01). In multivariate analysis, age (P=0.04), and preoperative skin color change (P=0.00) predicted a poorer response to therapy. The major limb amputations were performed in 2 limbs (2/41, 4.9%) of the emboli group, and 11 limbs (11/42, 26.2%) of the thrombi group. For the limb with thrombosis, the major limb amputations were performed in 9 limbs (9/26, 34.6%) of the thromboembolectomy group and in 2 limbs (2/16, 1.3%) of the arterial bypass group. CONCLUSION: These results suggest that prompt and appropriate treatment is critically important in the management of acute limb ischemia. In thrombi cases Especially, a more aggressive surgical approach may be necessary for limb salvage.
Amputation ; Aneurysm ; Catheters ; Classification ; Embolism ; Extremities* ; Female ; Gangrene ; Humans ; Incidence ; Ischemia* ; Limb Salvage ; Male ; Mortality ; Multivariate Analysis ; Retrospective Studies ; Risk Factors ; Skin ; Survival Rate ; Thrombolytic Therapy ; Thrombosis ; Transplants

PURPOSE: Whereas cyclosporine is increasingly used not only in transplantation but also in autoimmune disorders, it may be associated with several side effects. Gingival hyperpalsia is one of the most frequent side effects and has been estimated to occur in 21-30% of all patients receiving the drug and may require surgical correction. Azithromycin is a macrolide antibiotics reported to coincidentally reduce gingival hyperplasia in renal transplant recipients treated for respiratory infections. To confirm the effect of azithromycin in cyclosporine induced gingival hyperplasia we tried clinical use of azithromycin in renal transplant patients with severe gingival hyperplasia. METHODS: Patients (n=9) with cyclosporine induced gingival hyperplasia were selected and took azithromycin for 5 days. Follow-up visits were conducted at week 4 and week 8. Changes in gingival hyperplasia were evaluated by measuring the ratio of clinical crown height and width in each of the four central incisors. RESULTS: Significant improvements were observed in periodontal measurement. The pre-treatment ratio of clinical crown height and width was 1.04+/-0.14 and it was increased to 1.17+/-0.16 in 4 weeks and 1.22+/-0.15 in 8 weeks. 88.9% (8/9) of patients reported an improvement in clinical symptoms. Azithromycin was tolerated and 77.8% (7/9) of patients reported that the treatment was at least somewhat useful. CONCLUSION: Azithromycin treatment for cyclosporine induced gingival hyperplasia is efficacious, cost effective, and has less morbidity compared with gingivectomy.
Anti-Bacterial Agents ; Azithromycin* ; Crowns ; Cyclosporine ; Follow-Up Studies ; Gingival Hyperplasia* ; Gingivectomy ; Humans ; Incisor ; Respiratory Tract Infections ; Transplantation*

PURPOSE AND METHOD: To access the value and results of femoro-femoral bypass for the treatment of unilateral iliac artery occlusion, the clinical data of 53 patients who underwent femoro-femoral bypass graft at Yeungnam University Hospital between January 1994 to December 2000 were analyzed retrospectively. The influence of several variables (such as, age, sex, preoperative symptom, risk factors and associated medical illness, status of distal artery, preoperative ABI) on the long term patency was evaluated by univariate statistical analysis. RESULT: The patients were 47 males and 6 females ranging from 37 to 84 years of age. The mean age was 65, with the highest incidence among people in their 60s, followed by those in their 70s and then in their 50s. Associated diseases were hypertension in 28 cases (52.8%), diabetes mellitus in 10 cases (18.8%), cardiac disease in 19 cases (32.0%) and cerebrovascular disease in 4 cases (7.5%). History of smoking was noted in 77.4% of the cases. Focal stenosis of donor site iliac artery has been found in 2 cases and combined distal outflow occlusion has been found in 21 cases. 2 donor site iliac artery ballon angioplasty was performed preoperatively and 14 adjuvant procedures (9 femoro-popliteal bypass, 2 femoro-tibial bypass, 3 profundoplasty) was performed simultaneously during the operation. Cumulative 1, 3, 5,-year primary and secondary patency rates of all femoro-femoral bypass were 87.0%, 76.6%, 68.1% and 91.7%, 85.7%, 73.5%. There was no operative mortality and major perioperative complications. Univariate analysis showed that the patients without distal arterial occlusion had significantly better 1-, 3- and 5-year primary patency rates (93.0%, 89.0% and 74.2% versus 76.6%, 45.9% and 45.9%, P=0.02) compared with the patients with distal arterial occlusion. No significant effect was exerted by all other variables on long term results. CONCLUSION: These results suggest that femoro-femoral bypass is a safe and durable operation that results in good patency in a good runoff.
Angioplasty ; Arteries ; Constriction, Pathologic ; Diabetes Mellitus ; Female ; Heart Diseases ; Humans ; Hypertension ; Iliac Artery ; Incidence ; Male ; Mortality ; Retrospective Studies ; Risk Factors ; Smoke ; Smoking ; Tissue Donors ; Transplants*