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Reperfusion
Eur J Vasc Endovasc Surg 22, 186–187 (2001)
Correspondence Haemostatic Devices Sir, The article by Davis et al.1 highlights the risk of acute limb ischaemia, secondary to the use of vascular haemostasis devices (VHD) in patients with peripheral vascular disease. We recently experienced a similar case of acute limb ischaemia in a patient with established claudication, secondary to the use of the Angio-seal device. Arterial puncture had been performed for coronary vessel angiography. He presented 5 days later with acute limb ischaemia. Emergency surgery confirmed profunda artery thrombosis, secondary to the migration of the Angio-seal anchor. Reports of acute limb ischaemia secondary to the use of VHDs are becoming increasingly prevalent in the literature.1–3 We suspect this reflects the increased use of VHDs, to facilitate an increase in angiographic turnover. We, as vascular surgeons, would welcome a proper audit of VHD use, concentrating on risk factors such as peripheral vascular disease, anti-coagulation status and use of additional haemostasis devices, e.g. femostop. Angiography waiting list pressures must not prompt our radiological and cardiological colleagues to use VHDs inappropriately. S. Kuruvath and C. D. Irvine Wakefield, U.K. doi:10.1053/ejvs.2001.1426, available online at http://www.idealibrary.com on
References 1 Davis M, Jakeways MSR, Watkinson A, Hamilton G. Acute limb ischaemia secondary to a collagen plug device. Eur J Vasc Endovasc Surg 2000; 20: 581–583. 2 Wijesinghe LD, Coughlin PA, Gill K. An unusual cause of femoral embolus. Cardiovasc Surg 2000; 8: 287–288. 3 Goyen M, Manz S, Kroger K et al. Interventional therapy of vascular complications caused by the haemostatic puncture closure device Angio-seal. Cather and Cardiovasc Interv 2000; 49: 142– 147. 4 Prabhudesai A, Khan MZU. An unusual cause of femoral embolism Angio-seal. Ann R Coll Surg Engl 2000; 82. 5 Chamberlin JR, Lardi AB, McKeever LS et al. Use of vascular sealing devices (Vasoseal and perclose) versus assisted manual 1078–5884/01/080186+02 $35.00/0 2001 Harcourt Publishers Ltd.
compression (Femostop) in transcatheter coronary interventions requiring Abciximab (Reopro). Cather and Cardiovasc Interv 1999; 47: 143–147.
Ischaemia/Reperfusion Sir, We congratulate Reber et al. for their work on colonic ischaemia following aortic surgery which establishes a basis for future studies.1 Our main objection to this study is that the artery of Drummond was also clamped along with the other arteries. In aortic aneurysm repair hypoperfusion is present but there is no occlusion of the major communication between superior mesenteric and inferior mesenteric arterial circulation. In this non-atherosclerotic model, simulation of haemorrhagic shock has to be simulated by provoking massive bleeding in order to reveal the whole systemic response cascade and not by complete ischaemia.2,3 Moreover the intramural insertion of the PO2 probe seems risky on clinical basis. In an experimental study on pigs, we observed,4,5 like the authors, in the first group of the animals major injury involving all the layers of the sigmoid colon wall, after 2 h of total ischaemia which included occlusion by the infrarenal aorta, inferior mesenteric external and internal iliac arteries. In the second group, aiming in finding protective measures, we used a Pruitt–Inahara shunt in order to supply blood flow to inferior mesenteric injury but produced an equally high free radical load. The most rewarding result was in the third group where 30 min before the 2 h crossclamping of the arteries as in group A, we infused vitamin E (i.v. 75 mg/kg BW).6–8 The outcome was impressive: the intestinal injury was minimal, showing only slight inflammation of the mucosa and the free radical load was also reduced. When the intraoperative findings in aortic surgery suggest colon ischaemia, the reimplantation of a patent inferior mesenteric artery is obviously the first step, though the problem usually arises when the intestinal ischaemia presents postoperatively. Additionally in
Correspondence
surgery for POD (Y-grafts), the systemic disease, along with the reperfusion of the ischaemic lower limbs, increase the risk of injury in an already compromised large intestine. The intestinal damage due to the ischaemia/reperfusion syndrome is provoked mainly from the disturbance of the intestinal circulation which leads to increased outburts of reactive oxygen metabolites but is also due to the concurrent ischaemia/reperfusion of large muscular masses, e.g. lower limbs. Both provoke not only intestinal damage but injury to remote organs like lungs, heart or brain, also mediated by cell adhesion molecules.9,10 Studies like the one conducted by the authors are required not only to assess the physiological changes, but more importantly to test the usefulness of antioxidant agents or the necessity of a pump or shunt for peripheral perfusion during the cross-clamping period. T. E. Kotsis, P. B. Dimakakos Athens, Greece doi:10.1053/ejvs.2001.1427, available online at http://www.idealibrary.com on
187
References 1 Reber PU, Peter M, Patel AG et al. Ischaemia/reperfusion contributes to colonic injury during experimental aortic surgery. Eur J Vasc Endovasc Surg 2001; 21: 35–39. 2 Parks DA, Granger DN. Contributions of ischemia and reperfusion to mucosal lesion formation. Am J Physiol 1986; 250: G749–G753. 3 Schoenberg MH, Beger HG. Reperfusion injury after intestinal ischemia. Critical Care Medicine 1993; 21: 1376–1386. 4 Kotsis T, Dimakakos P, Katsenis K et al. Ischaemia–reperfusion syndrome during aortic cross-clamping: Preventive measures. Proceedings of 6th Greek Congress of Vascular Surgery—Athens 1999, pp. 44–45. 5 Dimakakos P, Kotsis T, Pafiti A et al. Oxygen free radicals in aortic surgery. An experimental study. J Cardiovasc Surg (under consideration). 6 Formigli L, Ibba Manneschi L, Tani A et al. Vitamin E prevents neutrophil accumulation and attenuates tissue damage in ischemic-reperfused human skeletal muscle. Histol Hisopathol 1997; 12: 663–669. 7 Hall E, Yonkers P, Horan K, Braughler M. Correlation between attenuation of posttraumatic spinal cord ischemia and preservation of tissue vitamin E by the 21-aminosteroid U74006F: evidence for an in vivo antioxidant mechanism. J Neurotrauma 1989; 6: 169–176. 8 Nagel E, Meyer zu Vilsendorf A, Brtels M, Pichlmayer R. Antioxidative vitamins in prevention of ischaemia/reperfusion injury. Int J Vitamin Nutr Res 1997; 67: 298–306. 9 Beyersdorf F, Sarai K, Mitrev Z et al. Kontrollierte extremitatenreperfusion: erst klinische ergebnisse. Angio 1993; 15: 101–110. 10 Nilsson U, Schoenberg M, Aneman A et al. Free radicals and pathogenesis during ischemia and reperfusion of the cat small intestine. Gastroenterology 1994; 106: 629–636.
Eur J Vasc Endovasc Surg Vol 22, August 2001
Correspondence Haemostatic Devices Sir, The article by Davis et al.1 highlights the risk of acute limb ischaemia, secondary to the use of vascular haemostasis devices (VHD) in patients with peripheral vascular disease. We recently experienced a similar case of acute limb ischaemia in a patient with established claudication, secondary to the use of the Angio-seal device. Arterial puncture had been performed for coronary vessel angiography. He presented 5 days later with acute limb ischaemia. Emergency surgery confirmed profunda artery thrombosis, secondary to the migration of the Angio-seal anchor. Reports of acute limb ischaemia secondary to the use of VHDs are becoming increasingly prevalent in the literature.1–3 We suspect this reflects the increased use of VHDs, to facilitate an increase in angiographic turnover. We, as vascular surgeons, would welcome a proper audit of VHD use, concentrating on risk factors such as peripheral vascular disease, anti-coagulation status and use of additional haemostasis devices, e.g. femostop. Angiography waiting list pressures must not prompt our radiological and cardiological colleagues to use VHDs inappropriately. S. Kuruvath and C. D. Irvine Wakefield, U.K. doi:10.1053/ejvs.2001.1426, available online at http://www.idealibrary.com on
References 1 Davis M, Jakeways MSR, Watkinson A, Hamilton G. Acute limb ischaemia secondary to a collagen plug device. Eur J Vasc Endovasc Surg 2000; 20: 581–583. 2 Wijesinghe LD, Coughlin PA, Gill K. An unusual cause of femoral embolus. Cardiovasc Surg 2000; 8: 287–288. 3 Goyen M, Manz S, Kroger K et al. Interventional therapy of vascular complications caused by the haemostatic puncture closure device Angio-seal. Cather and Cardiovasc Interv 2000; 49: 142– 147. 4 Prabhudesai A, Khan MZU. An unusual cause of femoral embolism Angio-seal. Ann R Coll Surg Engl 2000; 82. 5 Chamberlin JR, Lardi AB, McKeever LS et al. Use of vascular sealing devices (Vasoseal and perclose) versus assisted manual 1078–5884/01/080186+02 $35.00/0 2001 Harcourt Publishers Ltd.
compression (Femostop) in transcatheter coronary interventions requiring Abciximab (Reopro). Cather and Cardiovasc Interv 1999; 47: 143–147.
Ischaemia/Reperfusion Sir, We congratulate Reber et al. for their work on colonic ischaemia following aortic surgery which establishes a basis for future studies.1 Our main objection to this study is that the artery of Drummond was also clamped along with the other arteries. In aortic aneurysm repair hypoperfusion is present but there is no occlusion of the major communication between superior mesenteric and inferior mesenteric arterial circulation. In this non-atherosclerotic model, simulation of haemorrhagic shock has to be simulated by provoking massive bleeding in order to reveal the whole systemic response cascade and not by complete ischaemia.2,3 Moreover the intramural insertion of the PO2 probe seems risky on clinical basis. In an experimental study on pigs, we observed,4,5 like the authors, in the first group of the animals major injury involving all the layers of the sigmoid colon wall, after 2 h of total ischaemia which included occlusion by the infrarenal aorta, inferior mesenteric external and internal iliac arteries. In the second group, aiming in finding protective measures, we used a Pruitt–Inahara shunt in order to supply blood flow to inferior mesenteric injury but produced an equally high free radical load. The most rewarding result was in the third group where 30 min before the 2 h crossclamping of the arteries as in group A, we infused vitamin E (i.v. 75 mg/kg BW).6–8 The outcome was impressive: the intestinal injury was minimal, showing only slight inflammation of the mucosa and the free radical load was also reduced. When the intraoperative findings in aortic surgery suggest colon ischaemia, the reimplantation of a patent inferior mesenteric artery is obviously the first step, though the problem usually arises when the intestinal ischaemia presents postoperatively. Additionally in
Correspondence
surgery for POD (Y-grafts), the systemic disease, along with the reperfusion of the ischaemic lower limbs, increase the risk of injury in an already compromised large intestine. The intestinal damage due to the ischaemia/reperfusion syndrome is provoked mainly from the disturbance of the intestinal circulation which leads to increased outburts of reactive oxygen metabolites but is also due to the concurrent ischaemia/reperfusion of large muscular masses, e.g. lower limbs. Both provoke not only intestinal damage but injury to remote organs like lungs, heart or brain, also mediated by cell adhesion molecules.9,10 Studies like the one conducted by the authors are required not only to assess the physiological changes, but more importantly to test the usefulness of antioxidant agents or the necessity of a pump or shunt for peripheral perfusion during the cross-clamping period. T. E. Kotsis, P. B. Dimakakos Athens, Greece doi:10.1053/ejvs.2001.1427, available online at http://www.idealibrary.com on
187
References 1 Reber PU, Peter M, Patel AG et al. Ischaemia/reperfusion contributes to colonic injury during experimental aortic surgery. Eur J Vasc Endovasc Surg 2001; 21: 35–39. 2 Parks DA, Granger DN. Contributions of ischemia and reperfusion to mucosal lesion formation. Am J Physiol 1986; 250: G749–G753. 3 Schoenberg MH, Beger HG. Reperfusion injury after intestinal ischemia. Critical Care Medicine 1993; 21: 1376–1386. 4 Kotsis T, Dimakakos P, Katsenis K et al. Ischaemia–reperfusion syndrome during aortic cross-clamping: Preventive measures. Proceedings of 6th Greek Congress of Vascular Surgery—Athens 1999, pp. 44–45. 5 Dimakakos P, Kotsis T, Pafiti A et al. Oxygen free radicals in aortic surgery. An experimental study. J Cardiovasc Surg (under consideration). 6 Formigli L, Ibba Manneschi L, Tani A et al. Vitamin E prevents neutrophil accumulation and attenuates tissue damage in ischemic-reperfused human skeletal muscle. Histol Hisopathol 1997; 12: 663–669. 7 Hall E, Yonkers P, Horan K, Braughler M. Correlation between attenuation of posttraumatic spinal cord ischemia and preservation of tissue vitamin E by the 21-aminosteroid U74006F: evidence for an in vivo antioxidant mechanism. J Neurotrauma 1989; 6: 169–176. 8 Nagel E, Meyer zu Vilsendorf A, Brtels M, Pichlmayer R. Antioxidative vitamins in prevention of ischaemia/reperfusion injury. Int J Vitamin Nutr Res 1997; 67: 298–306. 9 Beyersdorf F, Sarai K, Mitrev Z et al. Kontrollierte extremitatenreperfusion: erst klinische ergebnisse. Angio 1993; 15: 101–110. 10 Nilsson U, Schoenberg M, Aneman A et al. Free radicals and pathogenesis during ischemia and reperfusion of the cat small intestine. Gastroenterology 1994; 106: 629–636.
Eur J Vasc Endovasc Surg Vol 22, August 2001