Conservative treatment of inoperable arterial occlusions of the lower extremities with intra-arterial prostaglandin E1

Prostaglandin E1 has a strong vasodilator effect, it inhibits the aggregation of platelets and improves the microcirculation. The hormone is synthesized from arachidonic acid and 80-90 per cent is eliminated in the first transit of the pulmonary circulation. From 1 January 1978 to 30 June 1981 100 patients suffering from inoperable occlusion of the arteries of the lower limbs and facing amputation were treated with intra-arterial PGE1 by prolonged perfusion over an average period of 34 days. PGE1 0.1-0.2 ng kg-1 body weight min-1 was administered. Forty-seven of 100 legs were saved; 22 of 29 patients suffering from diabetes requiring insulin had to undergo amputation, but only 1 of 18 patients suffering from thromboangiitis obliterans had to have an amputation. The results of treatment in the 52 cases of uncomplicated arteriosclerosis lie in between, with 18 amputations. The complications that followed treatment were haemorrhage, arterial thrombosis, infection and mycotic aneurysms.

Recurrent pulmonary emboli and Buerger's disease

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[Eighteen years' experience of thrombolytic therapy with streptokinase (author's transl)]

18 years clinical experience with thrombolytic therapy has shown that venous and arterial thrombotic occlusions which persist not only for a few days but also for weeks and 2 to 4 months can be dissolved in about 60-70% of the cases by intravenous infusion of streptokinase. Although this treatment is one of the great break-throughs of internal medicine in this century it is not yet in general use. The reason for this is that the risk of a deleterious bleeding is difficult to assess. This and also the numerous contraindications can be diminished by direct infiltration of an intravasal clot with a relatively small amount of streptokinase through a catheter.

The effects of prostacyclin on glycemia and insulin release in man

Prostacyclin /PGI2/ administered intra-arterially or intravenously to patients with peripheral vascular disease exerted a hyperglycemic effect. In normoglycemic patients receiving PGI2 at a dose of 5 ng/kg/min these effects were barely detectable, but they became unmasked by a rapid glucose injection. In diabetic patients the same PGI1 dose led to distinct elevation in blood glucose. Prostacyclin at a dose of 10 ng/kg/min raised blood glucose levels both at rest and after stimulation with glucose, and opposed effectively hypoglycemic action of tolbutamide in non-diabetic patients. PGI2 repressed glucose-induced insulin release in some normoglycemic patients but in others it either increased it or did not affect it. While hyperglycemic effects are reversible when PGI2 infusion is stopped, and do not interfere with the usual therapeutic administration of prostacyclin for a few days they, nevertheless, might constitute a risk in a patient with poorly controlled diabetes.

[Thrombangiitis obliterans: diagnosis and therapy in light of new immunological findings]

Thrombangiitis obliterans, a segmental, multilocal, inflammatory disease of the small and medium-sized arteries and veins, is characterized by the relatively juvenile onset of the disease, the peripheral localization of the arterial occlusions and by phlebitis saltans. Other diagnostic criteria are the absence of risk factors typical of atherosclerosis (except smoking), strictly localized occlusion on angiography, phasic clinical course, and exclusion of either collagen disease or essential thrombocytosis. A possible immunopathogenesis for the disease is increasingly favored. In our own study of 33 patients the complement factor C4 was increased in 54.6%, the antielastin antibodies were found at a titre of 1:8 in 57.1% and the immuncomplexes in 23.3%. In only 1 case was the histocompatibility antigen HLA B 12 absent. In view of these immunologic findings and also the fact that phlebitis saltans as a symptom of the disease can be suppressed by salicylates and corticosteroids, but not by anticoagulants, the following therapy is proposed: high doses of acetylsalicylic acid during the acute stage of the illness, or, if this regimen fails, a trial with corticosteroids or immunosuppressive agents.

Evaluation of a new alpha-blocking vasodilator agent (thymoxamine) in peripheral vascular disease

The effects on peripheral cutaneous blood-flow of the alpha-receptor blocking drug thymoxamine were measured by strain-gauge plethysmography in 58 subjects. The intravenous drug produced a substantial, though often transient, vasodilatation in the feet of normal subjects, and in most instances increased pedal blood-flow in non-sympathectomized patients with lower-limb arterial occlusions and healthy feet. In patients previously sympathectomized for either non-occlusive or occlusive disease of the lower limbs the effect of the drug was variable, even bringing about a reduction in pedal blood-flow in a number of cases. Intravenous thymoxamine regularly though briefly produced vasodilatation in the hands of patients sympathectomized for primary Raynaud'S disease, but the oral drug had no such action in most instances. It is concluded that systemic thymoxamine is unlikely to be of therapeutic benefit to the sympathecromized patient.