Impact of pH-adjusted fluoride and stannous solutions on the protective properties on the pellicle layer in vitro and in situ

This study evaluates the ideal pH for anti-erosion and anti-adherent efficacy of fluoride and stannous solutions (sodium fluoride (SF), amine fluoride (AF), sodium monofluorophosphate (SMFP), stannous fluoride (SnF2) with 500 ppm fluoride concentration each and stannous chloride (SnCl2, 1563 ppm stannous)). In vitro, solutions were tested at pH 4.5 and 5.5. The main in situ experiments were carried out at the pH of 4.5: For pellicle formation 6 volunteers wore bovine enamel slabs intraorally for 1 min, rinsed with 8 ml solution for 1 min and continued for up to 30 min/8 h. Physiological pellicle samples served as controls. After incubation in HCl (2.0, 2.3) for 2 min mineral release was determined photometrically. Bacterial counts on 8 h biofilms were determined by fluorescence microscopy (BacLight™ and DAPI with Concanavalin A). Modification of the pellicle ultrastructure was examined by TEM. Statistical analysis was performed using Kruskal-Wallis and Mann-Whitney-U tests with Bonferroni-correction (p < 0.05). SnF2 showed a significant erosion protection. AF, SnF2, and SnCl2 were most anti-adherent. SnF2 and SnCl2 caused a pronounced basal pellicle with stannous precipitates. Compared to other fluoride monosubstances, stannous ions offer greater protection against erosive acidic attacks. Stannous ions act as crucial co-factor in this process.

Polarization-Sensitive Optical Coherence Tomography for Monitoring De- and Remineralization of Bovine Enamel In Vitro

Early caries diagnosis still challenges dentistry. Polarization-sensitive optical coherence tomography (PS-OCT) is promising to detect initial lesions non-invasively in depth-resolved cross-sectional visualization. PS-OCT with determined degree of polarization (DOP) imaging provides an intuitive demineralization contrast. The aim of this study is to evaluate the suitability of DOP-based PS-OCT imaging to monitor controlled de- and remineralization progression for the first time and to introduce it as a valid, non-destructive in vitro detection method. Twelve standardized bovine enamel specimens were divided in different groups and demineralized with hydrochloric acid (HCl) as well as partly remineralized with fluoride over a 14-day pH-cycling experiment. The specimens were stored in artificial saliva and sodium chloride (NaCl), respectively. Progress measurements with PS-OCT were made with polarization-sensitive en faceand B-scan mode for qualitative evaluation. The specimens demineralized in HCl showed the most pronounced surface change (lowest DOP) and the most significant increase in depolarization. Additional fluoride treatment and the storage in artificial saliva resulted in the opposite (highest DOP). Therefore, DOP-based PS-OCT imaging appears to be a valuable technique for visualization and monitoring of enamel demineralization and remineralization processes in vitro. However, these findings need to be confirmed in human teeth ex vivo or in situ.

Erosion behaviour of human, bovine and equine dental hard tissues

Dental hard tissues from different species are used in dental research, but little is known about their comparability. The aim of this study was to compare the erosive behaviour of dental hard tissues (enamel, dentin) obtained from human, bovine and equine teeth. In addition, the protective effect of the pellicle on each hard tissue under erosive conditions was determined. In situ pellicle formation was performed for 30 min on enamel and dentin samples from all species in four subjects. Calcium and phosphate release was assessed during 120 s of HCl incubation on both native and pellicle-covered enamel and dentin samples. SEM and TEM were used to examine surface changes in native enamel and dentin samples after acid incubation and the ultrastructure of the pellicle before and after erosive exposure. In general, bovine enamel and dentin showed the highest degree of erosion after acid exposure compared to human and equine samples. Erosion of human primary enamel tended to be higher than that of permanent teeth, whereas dentin showed the opposite behaviour. SEM showed that eroded equine dentin appeared more irregular than human or bovine dentin. TEM studies showed that primary enamel appeared to be most susceptible to erosion.

Olive Oil as a Transport Medium for Bioactive Molecules of Plants?-An In Situ Study

(1) Caries and erosions still remain a challenge for preventive dentistry. Certain plant extracts have shown beneficial effects in preventive dentistry. The aim of this study was to evaluate the antibacterial, anti-adherent and erosion-protective properties of ellagic acid (EA) as a polyphenolic agent. The combination with olive oil was investigated additionally to verify a possible improved bioactive effect of EA. (2) An in situ study was carried out with six subjects. Individual splints were prepared with bovine enamel specimens. The splints were worn for 1 min (pellicle formation time). Thereafter, 10 min rinses were performed with EA in water/in oil. Bacterial adherence was evaluated by fluorescence microscopy (DAPI, ConA, BacLight) after an 8 h oral exposition time. Additionally, the splints were worn for 30 min to quantify demineralization processes. The ultrastructure of the pellicle was investigated after an oral exposure time of 2 h under a transmission electron microscope. Statistical analysis was performed by Kruskal-Wallis tests, Mann-Whitney U tests and Bonferroni-Holm correction. (3) Rinsing with EA led to a significant reduction of adherent vital and dead bacteria. The combination with olive oil did not improve these outcomes. The assessment of glucan structures after rinsing with EA in water showed significant effects. Significant differences were observed for both rinses in calcium release at pH 3.0. After rinsing with EA in oil, significantly less calcium was released compared to rinsing with EA in water (pH = 3.0). (4) Olive oil is not suitable as a transport medium for lipophilic polyphenols. EA has anti-adherent and antibacterial properties in situ. EA also shows erosion-protective effects, which can be enhanced in combination with olive oil depending on the pH value. Ellagic acid has a neutral pH and could be an opportunity in the treatment of specific patient groups (xerostomia or mucositis).

Efficacy of Endodontic Disinfection Protocols in an E. faecalis Biofilm Model-Using DAPI Staining and SEM

The aim of this study was to investigate the antimicrobial efficacy of different disinfection protocols in a novel Enterococcus faecalis biofilm model based on a visualization method and to evaluate the potential alteration of dentinal surface. A total of 120 extracted human premolars were allocated to 6 groups with different irrigation protocols. The assessment of the effectiveness of each protocol and the alteration of dentinal surface were visualized by using SEM and fluorescence microscopy (DAPI). A dense E. faecalis biofilm with a penetration depth of 289 μm (medial part of the root canal) and 93 μm (apical part) validated that the biofilm model had been successfully implemented. A significant difference between the 3% NaOCl groups and all the other groups in both observed parts of the root canal (p < 0.05) was detected. However, the SEM analysis revealed that the dentinal surface in the 3% NaOCl groups was severely altered. The established biofilm model and the visualization method based on DAPI are appropriate for bacterial quantification and evaluation of the depth effect of different disinfection protocols in the root canal system. The combination of 3% NaOCl with 20% EDTA or MTAD with PUI allows the decontamination of deeper dentine zones within the root canal but simultaneously alters the dentinal surface.

Direct and indirect effects of different dentifrices on the initial bacterial colonization of enamel in situ overnight

OBJECTIVE

The aim of this study was to investigate the direct and indirect influence of fluoridated toothpastes and fluoride-free toothpaste with hydroxyapatite (HAP) as active ingredient on initial bacterial colonization on enamel in situ.

METHODS

For this clinical-experimental pilot study, eight subjects were instructed to brush their teeth with three different toothpastes (Elmex^® : 1400 ppm AmF, Meridol^® : 1400 ppm AmF +SnF2, Karex^® : HAP), using each for two consecutive days. As a control, brushing without toothpaste was performed. To evaluate bacterial colonization, subject wore splints with buccally placed bovine enamel platelets overnight. Two modes were tested. In a first pass (regimen A), the splints were inserted after toothbrushing to examine the indirect effects of the dentifrices. In order to investigate the direct effects, the specimens were brushed in situ in a second pass (regimen B). Biofilm formation was visualized and quantified using fluorescence microscopy (DAPI and BacLight) and transmission electron microscopy (TEM).

RESULTS

For brushing regimen A (indirect effect of dentifrices), no statistical differences were detected between any of the tested dentifrices or the control. Likewise, no statistically significant differences were recorded for brushing regimen B (direct effect of dentifrices). Furthermore, no differences between the different brushing techniques were determined with regard to the ultrastructure of the overnight biofilm.

CONCLUSION

Within the limitations of the present pilot study, it can be concluded that in patients with good oral hygiene, dentifrices and their chemical composition have no statistically significant effect on the initial bacterial colonization of enamel platelets in situ, irrespectively of the mode of application.

Quantification of Bacterial DNA from Infected Human Root Canals Using qPCR and DAPI after Disinfection with Established and Novel Irrigation Protocols

The removal of bacterial infections within the root canal system is still a challenge. Therefore, the cleansing effect of established and new irrigation-protocols (IP) containing silver diamine fluoride (SDF) 3.8% on the whole root canal system was analyzed using quantitative PCR (qPCR) and 4′,6-diamidino-phenylindole-(DAPI)-staining. Extracted human premolars were instrumented up to F2 (ProTaper Gold) under NaCl 0.9% irrigation and incubated with Enterococcus faecalis for 42 days. Subsequently, different ultrasonically agitated IP were applied to the roots: control (no irrigation), 1. NaOCl 3%, EDTA 20%, CHX 2%, 2. NaOCl 3%, EDTA 20%, 3. NaOCl 3%, EDTA 20%, SDF 3.8%, 4. SDF 3.8%, and 5. NaCl 0.9%. One half of the root was investigated fluorescent-microscopically with DAPI. The other half was grinded in a cryogenic mill and the bacterial DNA was quantified with qPCR. The qPCR results showed a statistically significant reduction of bacteria after the application of IP 1, 2, and 3 compared to the control group. While IP 4 lead to a bacterial reduction which was not significant, IP 5 showed no reduction. These data corresponded with DAPI staining. With qPCR a new molecular-biological method for the investigation of the complete root canal system was implemented. The novel IP 3 had an equally good cleansing effect as the already established IP.

Bioadhesion on Textured Interfaces in the Human Oral Cavity-An In Situ Study

Extensive biofilm formation on materials used in restorative dentistry is a common reason for their failure and the development of oral diseases like peri-implantitis or secondary caries. Therefore, novel materials and strategies that result in reduced biofouling capacities are urgently sought. Previous research suggests that surface structures in the range of bacterial cell sizes seem to be a promising approach to modulate bacterial adhesion and biofilm formation. Here we investigated bioadhesion within the oral cavity on a low surface energy material (perfluorpolyether) with different texture types (line-, hole-, pillar-like), feature sizes in a range from 0.7–4.5 µm and graded distances (0.7–130.5 µm). As a model system, the materials were fixed on splints and exposed to the oral cavity. We analyzed the enzymatic activity of amylase and lysozyme, pellicle formation, and bacterial colonization after 8 h intraoral exposure. In opposite to in vitro experiments, these in situ experiments revealed no clear signs of altered bacterial surface colonization regarding structure dimensions and texture types compared to unstructured substrates or natural enamel. In part, there seemed to be a decreasing trend of adherent cells with increasing periodicities and structure sizes, but this pattern was weak and irregular. Pellicle formation took place on all substrates in an unaltered manner. However, pellicle formation was most pronounced within recessed areas thereby partially masking the three-dimensional character of the surfaces. As the natural pellicle layer is obviously the most dominant prerequisite for bacterial adhesion, colonization in the oral environment cannot be easily controlled by structural means.

Influence of pure fluorides and stannous ions on the initial bacterial colonization in situ

The present clinical-experimental study aims to examine the effect of pure experimental fluoride solutions and stannous chloride on the initial oral bioadhesion under in situ conditions. After 1 min of pellicle formation on bovine enamel slabs, 12 subjects rinsed with 8 ml of the fluoride test solutions (NaF, Na2PO3F, AmF, SnF2,) with 500 ppm fluoride concentration each for 1 min. Additionally, rinsing without a solution (control) and rinsing with 1563 ppm SnCl2 solution took place for 1 min. Afterwards, fluorescence microscopy took place to visualize bacterial adhesion and glucan formation (8 h oral exposition) with DAPI and ConA and the BacLight method. TEM was performed to visualize the pellicle ultrastructure together with EDX to detect stannous ions. The rinsing solutions with pure SnF2 and SnCl2 reduced significantly the initial bacterial colonization (DAPI). While, NaF and Na2PO3F showed no significant effect compared to the control. There was no significant difference between AmF, SnF2 and SnCl2. All tested experimental solutions showed no reducing effect on the glucan formation. Considerable alterations of the pellicle ultrastructure resulted from rinsing with the Sn-containing solutions. SnF2 appears to be the most effective type of fluoride to reduce initial bacterial colonization in situ. The observed effects primarily have to be attributed to the stannous ions' content.

Impact of customary fluoride rinsing solutions on the pellicle's protective properties and bioadhesion in situ

This study investigated the impact of customary fluoride based mouthrinses on the ultrastructure and the functional properties of the in situ pellicle, considering the prevention of erosion (8 volunteers) and initial biofilm formation (12 volunteers). Bovine enamel slabs were carried intraorally. After 1 min of pellicle formation, the subjects rinsed with elmex Kariesschutz (A), Dontodent Med Care (B), meridol (C) or elmex Zahnschmelzschutz Professional (D) for 1 min. In situ pellicle formation was continued up to 30 min/8 h before processing the slabs in vitro. Erosion was simulated by incubating the specimens in HCl (pH 3.0, 2.3, 2.0) for 120 s, measuring the kinetics of calcium/phosphate release photometrically; representative samples were evaluated by TEM and EDX. Bacterial adhesion was visualized fluorescence microscopically (DAPI/BacLight). Native enamel slabs or physiological pellicle samples served as controls. All investigated mouthrinses enhanced the erosion preventive pellicle effect in dependence of the pH-value. A significant decrease of Ca/P release at all pH values was achieved after rinsing with D; TEM/EDX confirmed ultrastructural pellicle modifications. All mouthrinses tendentially reduced bacterial adherence, however not significantly. The mouthrinse containing NaF/AmF/SnCl₂ (D) offers an effective oral hygiene supplement to prevent caries and erosion.

Is it really penetration? Locomotion of devitalized Enterococcus faecalis cells within dentinal tubules of bovine teeth

OBJECTIVE

The aim of the present study was to evaluate the penetration characteristics of devitalized and vital E. faecalis cells into root dentinal tubules.

DESIGN

Thirteen root canals were incubated with devitalized (4days, 7days, 14days, 28days) and vital (28days) E. faecalis strains (streptomycin-resistant strains) after root canal enlargement (size 80, taper 0.02) with 3 % NaOCl solution. The smear layer was intentionally removed with 20 % EDTA before inoculation. Samples were processed for analysis by scanning electron microscopy (SEM) and DAPI (4',6-diamidino-2-phenylindole) staining. DAPI was conducted for fluorescence microscopic visualization of the bacterial penetration into dentinal tubules. The penetration depth was calculated with the measurement tool of the Axio Vision program (Zeiss, Jena, Germany).

RESULTS

Devitalized E. faecalis strains were able to penetrate into dentinal tubules of the root canal. Apikal penetration depths of the devitalized cells were 100.67μm±26.54μm after 7days, 230.67μm±111.5μm after 14days and 266.5μm±92.63μm after 28days of incubation. The total number and penetration depth of E. faecalis cells was lower compared to a vital suspension of E. faecalis (1002.45μm) after 28days. It was noted that bacterial penetration was not common to all of the dentinal tubules in the vital E. faecalis control and especially in the devitalized control.

CONCLUSIONS

Increased exposure times of devitalized bacteria into root canals lead to an increased number of penetrated dentinal tubules as well as to a deeper penetration.

Initial microbial colonization of enamel in children with different levels of caries activity: An in situ study

PURPOSE

To investigate patterns of overnight in situ microbial colonization of enamel in children.

METHODS

Overall, 29 children (aged 5-9 years) participated in the study. Nine were caries-free with no decayed, missing, or filled teeth (DMFT), 11 were caries-rehabilitated (DMFT ≥ 2, no active carious lesions), and nine were caries-active (DMFT ≥ 2, at least two carious lesions). Bovine enamel samples were fixed on individual upper jaw splints stored overnight in situ. 4',6-diamidino-2-phenylindole (DAPI) combined with Concanavalin A staining was applied for fluorescence microscopic visualization of total adherent bacteria and glucans. Fluorescence in situ hybridization (FISH) was used for distinction of eubacteria, streptococci, and Candida albicans. Salivary samples were investigated for Streptococcus mutans (S. mutans) by using CRT bacteria test and yeasts with Calcofluor white (CFW) staining.

RESULTS

With all fluorescence methods, bacteria but not Candida albicans were detected on enamel samples. No statistically significant differences were observed in distribution patterns of the adherent bacteria between the groups. CFW staining indicated fungal structures in saliva samples of all participants. Based on CRT test results, the lowest amount of S. mutans were observed in caries-free children. Thus, initial microbial colonization patterns of enamel in children are not influenced by caries activity.

CLINICAL SIGNIFICANCE

Caries activity in children may influence the process of initial bioadhesion and thus distribution patterns of bacterial attachment to the enamel surface. Investigation of in situ biofilm formation might provide valuable insights regarding the varying caries susceptibility in children.

Enzymology and Ultrastructure of the in situ Pellicle in Caries-Active and Caries-Inactive Patients

Aim: The present study aimed to evaluate the impact of caries activity on the key enzymes and the ultrastructure of the in situ pellicle. Methods: Pellicle formation was performed on bovine enamel slabs. Intraoral exposure (3, 30, and 120 min) was accomplished by 14 caries-active (DMFS: 22.7 ± 12.1) and 13 caries-inactive (DMFS: 1.5 ± 1.8) individuals. The enzyme activities (lysozyme, peroxidase, α-amylase, glycosyltransferase [GTF]) in the in situ pellicle and resting saliva of all participants were analyzed directly after oral exposure. In addition, a simultaneous visualization of these enzymes, extracellular glucans, and adherent bacteria was carried out. Fluorescent patterns were analyzed with fluorescence labeling and 4′,6-diamidino-2-phenylindole/concanavalin A staining. In addition, the distribution of GTF B, C, and D and the ultrastructure of the pellicle were examined by gold immunolabeling and transmission electron microscopy with selected samples. Results: Enzyme activities of amylase, peroxidase, lysozyme, and GTF were detected on all enamel slabs in an active conformation. Neither exposure time nor caries activity had an impact on the enzyme activities. Gold immunolabeling indicated that the pellicle of caries-active subjects tends to more GTF D molecules. The pellicles of caries-inactive and -active individuals revealed a similar ultrastructural pattern. Conclusion: The enzyme activities as well as the pellicle's ultrastructure are of high similarity in caries-active and -inactive subjects. Thereby, oral exposure time has no significant influence. This reflects a high uniformity during the initial phase of bioadhesion (3-120 min) concerning enzymatic functions. However, there is a tendency towards more GTF D in caries-active individuals.

Effect of Tannic Acid on the Protective Properties of the in situ Formed Pellicle

OBJECTIVES

In the present in situ/ex vivo study the impact of tannic acid on the erosion-protective properties of the enamel pellicle was tested. Additionally, the antiadherent and antibacterial effects of tannic acid were evaluated.

METHODS

The pellicle was formed in situ on bovine enamel samples fixed on individual splints worn by 6 subjects. Following 1 min of pellicle formation the volunteers rinsed for 10 min with tannic acid. After further oral exposure for 19 min, 109 min, and 8 h overnight, respectively, slabs were incubated in HCl ex vivo (pH 2.0, 2.3, 3.0) over 120 s. Subsequently, kinetics of calcium and phosphate release were measured photometrically. Samples after a 1-min fluoride mouth rinse as well as enamel samples with and without a 30-min in situ pellicle served as controls. Antiadherent effects were evaluated after a 1-min rinse with tannic acid and oral exposure of the slabs overnight. DAPI (4',6-diamidino-2-phenylindole) combined with concanavalin A staining and live/dead staining was used for fluorescence microscopic visualization and quantification of adherent bacteria and glucans. Modification of the pellicle's ultrastructure by tannic acid was evaluated by transmission electron microscopy (TEM).

RESULTS

Tannic acid significantly improved the erosion-protective properties of the pellicle in a pH-dependent manner. Bacterial adherence and glucan formation on enamel were significantly reduced after rinses with tannic acid as investigated by fluorescence microscopy. TEM imaging indicated that rinsing with tannic acid yielded a sustainable modification of the pellicle; it was distinctly more electron dense.

CONCLUSION

Tannic acid offers an effective and sustainable approach for the prevention of caries and erosion.

The Polyphenolic Composition of Cistus incanus Herbal Tea and Its Antibacterial and Anti-adherent Activity against Streptococcus mutans

The Mediterranean plant Cistus incanus is rich in polyphenols and has shown several pharmacological activities, mainly antibacterial effects. Furthermore, in situ studies revealed that a C. incanus infusion reduces the initial bacterial adhesion in the oral cavity due to the polyphenols, an indication that C. incanus might reduce the risk of caries disease. In the present study, the polyphenols from four different commercial C. incanus herbal teas were extracted by standardized accelerated solvent extraction for in vitro tests and by an infusion for in situ tests. Both extracts were characterized qualitatively and quantitatively by high-performance liquid chromatography and only the polyphenol content differed slightly. By means of diode array detection and mass spectrometry, 29 polyphenols, including ellagitannins, flavanols, and glycosylated flavonols, were identified. Thereby, only quantitative but no qualitative differences between the four samples were detected. Furthermore, the in vitro antibacterial activity of the C. incanus accelerated solvent extracts against Streptococcus mutans, one of the primary cariogenic bacterial species, was examined using a live/dead assay (BacLight®). With this approach, C. incanus yielded antibacterial properties. Additional in situ experiments indicated that rinses with a C. incanus infusion reduced the initial bacterial colonization of enamel samples exposed to oral fluids for over eight hours. Furthermore, it was shown by transmission electron microscopy that the application of a C. incanus infusion modifies the ultrastructure of the acquired enamel pellicle, yielding a more electron-dense morphology. It can be assumed that the polyphenols are responsible for the observed effects.

Endovascular embolisation therapy in men with erectile impotence due to veno-occlusive dysfunction

OBJECTIVES

To evaluate the impact of endovascular embolisation therapy in men with erectile impotence due to veno-occlusive dysfunction.

METHODS

We retrospectively evaluated 29 patients with a history of erectile impotence due to veno-oclusive dysfunction confirmed by pharmacocavernosometry and cavernosography. All underwent endovascular embolisation therapy over transfemoral approach. After positioning the catheter system at the target level heights, embolisation with N-butyl-2-cyanoacrylate (Histoacryl(®)) was performed. Technical and clinical success as well as major and minor complications were evaluated.

RESULTS

All procedures were performed without any major or minor events. Complication rate was 0%. Technical success was achieved in 27/29 (93.1%). Two patients failed for anatomical reasons. Overall clinical success was achieved in 24/27 (88.8%) patients with recovering from E1 (poor tumescense/no rigidity) to E4 (good tumescence/intermediate rigidity) in 11/27 (40.7%), E1 to E5 in 8/27 (tumescence/normal rigidity) (29.6%) and E1 to E3 (good tumescence/poor rigidity) in 5/27 (18.5%) respectively. 3/27 (11.1%) received no change in ED severity score.

CONCLUSION

Endovascular embolisation therapy for veno-occlusive dysfunction in erectile impotence is a safe and effective therapeutic option with low complication rate and highly technical and clinical success rates.

[Incidence of ischemic lesions in diffusion-weighted imaging after transbrachial digital subtraction angiography]

PURPOSE

To evaluate the frequency of ischemia after transbrachial digital subtraction angiography under ambulant conditions using diffusion-weighted imaging.

MATERIALS AND METHODS

200 patients were included in a prospective study design and received transbrachial digital subtraction angiography under ambulant conditions. Before and after digital subtraction angiography, diffusion-weighted imaging of the brain was performed.

RESULTS

In our study population no new lesions were found in diffusion-weighted imaging after digital subtraction angiography during the 3-hour window after angiography. One new lesion was found 3 days after angiography as a late onset complication. Therefore, the frequency of neurological complications is at the level of the confidence interval of 0 - 1.5 %.

CONCLUSION

The transbrachial approach under ambulant conditions is a safe method for digital subtraction angiography resulting in a low rate of ischemic lesions in diffusion-weighted imaging.

[Interventional revascularization for severe mesenteric ischemia in contribution with venal artery angioplasty]

A 82 year old lady presented with haemorraghic erosive gastritis, progressing lost of weight, hypertension, diabetes mellitus and renal dysfunction. Colour flow duplex scanning and MRA revealed subtotal stenosis of the celiac artery and the right renal artery, proximal occlusion of the superior mesenteric artery and complete occlusion of the inferior mesenteric artery. There were also stenoses in the left renal artery. The patient was accessed via the left brachial artery, because of the relatively unfavourable angle of the mesenteric arteries. The procedures were done using F8-sheath-, F7-guiding catheter and vertebral shaped F5-diagonstic catheter. The celiac trunk und the right renal artery were initially treated with 7 x 12 and 5 x 17 mm balloon-expanding Stents. 7 x 40 mm self-expanding stent (Carotid wallstent) was inserted in the superior mesenteric artery following balloon dilatation with 5-mm-PTA-ballon. Dilatation of the superior mesenteric artery was done also after placement of the stent with 7-mm-PTA-ballon. One stage successful endovascular treatment was performed in the three vascular territories. A follow-up of 3 months period with colour duplex sonography revealed the stent to be patent with normal flow, better control of the hypertension and improvement of the renal function.

Transbrachial angiography: an effective and safe approach

Background: Description of the technique of the transbrachial catheter diagnostics, retrospective evaluation of the technical success rate and the complications. Patients and methods: In a period of 8 years the transbrachial approach was used in 2555 patients, 1734 men and 821 women with an average age of 62.9 years. The investigation was done with outpatients in approximately 90% of the cases. Usually, the preferred arm was not punctured. For the diagnostics F4 and F5-catheter sheaths and selective catheter and/or plain catheters were used. Results: 12 times (0.47%) the investigation did not succeed technically. The image quality of the vascular representations was diagnostically sufficient. The total complication rate amounted to 0.47%. The following complications appeared: four dissections in the site of puncture, one embolism into arteries at the forearm, three transitory ischemic attacks, four haematoma at the site of puncture. Conclusions: The transbrachial catheter diagnostics is a little invasive, efficient and low-risk method, which is practicable in out-patients.

The brachial artery as approach for catheter interventions – indications, results, complications

Background: Evaluation of the technical practicability of the acute results and complications with transbrachial catheter interventions. Patients and methods: Retrospective investigation of 156 catheter interventions with 147 patients within the period of 4/2000 to 12/2003. Target vessel, technical success, complications and in- or out-patient' practicability received special consideration. Results: The intervention was technically successful in 94%, 10 times segment obliterations of the distal femoral artery could not be recanalised. Renal arteries and mesenteric arteries going off steeply, processes of the femoral bifurcation, bypass stenosis, bilateral distal vascular processes as well as difficult puncturable or not puncturable inguinal arteries are particularly suitable for transbrachial procedure. Three complications arose, two haematoma, conservatively treated, and one cerebrovascular insult. Conclusions: Many vascular processes can be treated without any problem by transbrachial approach. The technical success rates are very high. The interventions can be realized without hopitalisation of the patient, except for some special cases (renal arteries and mesenteric arteries). The complication rate is low, condition is a large experience of the examiner.

Graduierung von Karotisstenosen mittels hochaufgelöster dynamischer MR-Angiographie im Vergleich zur intraarteriellen DSA. Können Stenosen über 70 % zuverlässig erkannt werden?

PURPOSES

Evaluation of high resolution dynamic magnetic resonance angiography (ceMRA) in detection and graduation of carotid artery stenosis in comparison to intraarterial digital subtraction angiography.

MATERIALS AND METHODS

Magnetic resonance angiography and intraarterial digital subtraction angiography was performed in 65 patients with suspected carotid artery stenosis by ultrasound examination. Detection and graduation of carotid artery stenosis by magnetic resonance angiography were compared to those of intraarterial digital subtraction angiography after stenosis grading according to NASCET criteria.

RESULTS

All magnetic resonance angiographies were of excellent quality, with 46 stenoses type I and II and 12 stenoses type III NASCET correctly identified and classified by magnetic resonance angiography. Overestimation was found in 4 cases and underestimation in 2 cases. Both modalities detected 13 occlusions. Sensitivity and specificity of ceMRA were 92%. The positive predictive value was 86% and the negative predictive value 96%.

CONCLUSION

High resolution dynamic magnetic resonance angiography is suitable in detecting and classifying carotid artery stenoses over 70% with high sensitivity and specificity in comparison to intraarterial digital subtraction angiography. Intraarterial digital subtraction angiography should only be performed in critical cases.

[CT Venography and CT Angiography of the Pulmonary Arteries in Acute Pulmonary Embolism]

OBJECTIVES

To determine the diagnostic value of CT venography after CT angiography of the pulmonary arteries using multislice helical CT in the diagnosis of acute pulmonary embolism.

METHODS

Between September 1999 and April 2001 252 patients with clinically suspected pulmonary embolism were examined. CT angiography of the pulmonary arteries was followed by CT venography of the inferior vena cava, the iliac veins and the proximal femoral veins; after April 2000 the popliteal veins and the proximal lower leg veins were additionally investigated. The examinations were performed with a double detector and a multidetector scanner (Elscint Twin and GE Lightspeed).

RESULTS

Pulmonary embolism was found in 79/252 patients (40 central and 39 segmental/subsegmental PE). In 38/40 patients with central PE and in 22/39 patients with segmental/subsegmental PE in CT venography a deep venous thrombosis was detected, in 1/79 patient a doubled inferior vena cava could be found. In 5 patients with thrombosis of the inferior vena cava a transjugular cava filter placement was performed. In 13/173 patients without pulmonary embolism CT venography showed deep venous thrombosis.

CONCLUSION

CT venography of the lower extremities is a practical and efficient additional examination to CT angiography in clinical suspected pulmonary embolism. It can detect the causing venous thrombosis with a high sensitivity.

Prepubertal high flow priapism: incidence, diagnosis and treatment

PURPOSE

We reviewed the literature of the last 40 years and report our experience with treating high flow priapism with fistula embolization in prepubertal boys.

MATERIALS AND METHODS

Two boys had blunt perineal trauma and 1 had penile trauma (ages 6, 6 and 10 years). Painless priapism developed within 24 hours and lasted for 4 to 7 days before the patients presented to the hospital. Primary diagnosis was made on color Doppler ultrasound. When high flow priapism was diagnosed angiography of the internal iliac artery and embolization of the arteriocavernosal fistula were performed. Mean followup was 26 months.

RESULTS

Color Doppler ultrasound revealed bilateral arteriocavernosal fistulas in 2 boys and a unilateral fistula in 1. Angiography showed fistulas of the branches of the internal pudendal artery in 2 patients and fistulas of the bulbourethral artery in 1. Microcoils were used in the bulbourethral artery and a gelatin sponge was used in other penile arteries. Complete detumescence with restored erectile function was achieved in all cases.

CONCLUSIONS

High flow priapism in children can be diagnosed easily by typical clinical features combined with color Doppler ultrasound. In children with posttraumatic priapism embolization of the arteriocavernosal fistula is superior to surgical or medical procedures and should be the first line therapy. Embolization using microcoils for bulbourethral arteries and a gelatin sponge for other penile arteries has proved to be safe and successful therapy.

Fragmentation of massive pulmonary embolism using a pigtail rotation catheter

STUDY OBJECTIVES

The purpose of this study was the evaluation of the efficacy and safety of mechanical fragmentation of acute massive pulmonary emboli with a rotatable pigtail catheter.

MATERIAL AND METHODS

Ten patients (4 female, 6 male, age 53.8+/-9.5 years) with acute massive pulmonary embolism with hemodynamic impairment were included in the study. The fragmentation catheter device (William Cook Europe A/S; Bjaerverskov, Denmark) consisted of a 5F catheter embedded in a flexible 5.5F sheath. Pulmonary emboli were fragmented by mechanical action of the recoiled rotating pigtail, while the guide wire was exiting an oval side hole proximal to the pigtail tip. In eight cases, an additional thrombolysis was performed.

RESULTS

Fragmentation was successful in 7 of 10 patients. Average percentage of recanalization by fragmentation was 29.2+/-14.0%, and 36.0+/-10.0% exclusively of the seven successful cases. Average shock index decreased significantly prefragmentation to postfragmentation from 1.52 to 1.22 (p = 0.03) and to 0.81 48 h later (p < 0.001). Decrease of the average mean arterial pulmonary pressure prefragmentation to postfragmentation was insignificant (from 33 to 31 mm Hg, p = 0.14); further decrease within the 48 h follow-up was highly significant (from 31 to 21 mm Hg, p < 0.001) due to a synergy of fragmentation and thrombolysis (average dose 63+/-25 mg plasminogen activator). There were no procedure-related complications. Overall mortality rate was 20%.

CONCLUSION

Fragmentation of massive pulmonary emboli with the pigtail rotation catheter achieved rapid partial recanalization in most cases, with ease of instrumentation, and without complications. Hemodynamic stabilization was completed in synergy with thrombolysis.

[Quality criteria in using percutaneous transluminal angioplasty of supra-aortic arteries]

OBJECTIVE AND METHOD

On the basis of 252 personally performed angioplasties and almost 2000 published results of percutaneous transluminal angioplasties (PTA) in supra-aortic arteries quality criteria for PTA in supra-aortic arteries are to be elaborated with special reference to the carotid artery.

RESULTS

To keep the complication rates low the indication must be strictly observed and particular attention paid to the morphological criteria. Experience has shown that PTA should be applied in brachiocephalic arteries only in the presence of symptomatic, high-grade, circular or short stenosis and smoothwalled stenosis without ulceration or severe calcification. In support of the angiography, intravascular ultrasound tomography is recommended for therapy control to ensure the quality. The application of stents is only useful when the result of the angioplasty is suboptimal and dissections and/or intimal flaps can be detected. Occlusion of the subclavian artery should be dilated by primary stent application. Quality can be assured by the use of modern instruments including investigational systems. The proper performance of angioplasty necessitates monitoring by means of EEG and ECG as well as close supervision of the pressure applied for dilatation. The quality and the documentation of the angioplasty results are ensured by post-therapeutic controls using angiography, intravascular ultrasound tomography and cerebral computer tomography. Good long-term success can only be achieved with the aid of post-therapeutic oral anticoagulant therapy. Application of angioplasty in supra-aortal arterial obliteration can result in an average morbidity of 0.9% with no or only minimal lethality if the necessary quality criteria are observed.

CONCLUSIONS

Whereas percutaneous transluminal angiography of the subclavian artery and the vertebral artery can be regarded as the therapy of choice, the results of prospective multicentre studies will have to be awaited before it can be assigned a place in carotid angioplasty.

[Partial portal vein and mesenteric vein thrombosis in familial protein S deficiency]

Protein S, a vitamin-K dependent glycoprotein is a cofactor of protein-C system, which acts as an inhibitor of the plasmatic coagulation. Protein-S congenital deficiency results in recurrent venous thromboses, atypical locations in portal and mesenteric veins are possible. In our patient the partial thrombosis of the portal vein was diagnosed by computed tomography and angiography. Small bowel ischaemia due to mesenteric vein thrombosis required segmental resection. Post-operatively the patient was heparinized and later phenprocoumon was applied to a long-term therapy.

[CT-guided manual afterloading with 198-gold seeds in intracerebral tumors]

Interstitial brachytherapy of intracerebral tumours was stimulated through the introduction of computed tomography and afterloading technique. Biopsies for their histologic verification as well as the stereotactic implantation of plastic tubes and adjusted to the extent of the tumour can be carried out with a high degree of exactitude by means of CT-supported localization and puncture. The small-sized 198-gold seeds are then introduced according to the manual afterloading technique and remain in situ until the planned dose in the target volume of 50 Gy is achieved. Report on our manual afterloading brachytherapy in high-grade astrocytomas III and IV and in adenomas of the hypophysis. Indications of the diagnostic and therapeutic procedure, irradiation planning, calculation of the dose and discussion of our tentative clinical experience are explained.

[Balloon dilatation and local thrombolysis in massive pulmonary embolism--initial results of a new therapy concept]

The high mortality rate among patients suffering from massive pulmonary embolism makes it imperative to act quickly. The first and foremost goal must be to lower the pulmonary pressure rapidly and to relieve the right ventricle. In three patients with massive pulmonary embolism we therefore tried to crush the thrombus by means of a balloon catheter. The diameters of the balloons were adapted to the size of the vessels to be treated; the balloon diameters were between 10 and 20 mm. Recanalisation resulted in a rapid improvement of perfusion and haemodynamic relief of the right ventricle. This was clinically documented by the drop in pulmonary pressure levels and an impressive improvement of general well-being. Dilation was followed by thrombolytic therapy adapted to the relevant situation. This method of thrombus crushing by means of balloon catheters is indicated in case if massive thrombi in the main stem of the a. pulmonalis, with elevated pulmonary pressure levels, and corresponding clinical signs and symptoms. It can follow alternatively as a first possibility of pressure relief directly after diagnostic pulmangiography. The initial clinical results of this new treatment method are most encouraging. Complications have not been observed so far.

[Acute cor pulmonale as a sequela of tumor embolism]

It is reported on a 22-year-old female patient with a chondroplastic osteosarcoma in the sacrum in whom in the course of her disease a massive embolism due to a tumour developed under the clinical picture of an acute pulmonary embolism. The clinical tentative diagnosis of a massive pulmonary embolism was confirmed by means of lung perfusion scintigram and pulmonary angiography. All efforts for a rapid recanalisation of the left pulmonary trunk by means of mechanical alteration, use of balloon catheter and subsequent thrombolysis were without success. Pathologo-anatomically a recurred tumorous thrombus embolism with an extensive pulmonary infarction in the left inferior lobe of the lung was found. The incidence as well as diagnostic viewpoints of embolisms due to tumour are discussed.

[Complications in cerebral angiography. A study of 6698 cerebral angiographies]

The complications of 6,698 cerebral angiographies performed from 1979 to 1985 in 2,503 patients were analysed. In 5.24% of the patients (1.95% of the angiopathies) temporary complications could be observed. Temporary neurologic-psychiatric complications occurred in 1.96% of the patients (0.73% of the angiographies), most of them in middle-aged patients and in the presence in the presence of diffuse cerebrovascular disease. In 0.12% of the patients (0.05% of the angiographies) a permanent damage was recorded.

[The results of percutaneous transvascular sclerotherapy of varicoceles]

The indications, techniques, complications and results of percutaneous sclerotherapy or embolization of gonadal veins for varicocele are discussed. Of our 93 patients, sclerotherapy of varicocele was technically possible in 81 cases. Sclerotherapy or embolization can be effected by different materials, such as: Histoacryl and Lipidiol mixed 1:2 to 1:4 and Aethoxysklerol, applied by a coaxial catheter system or end-opened F 6-catheter. Today the percutaneous transluminal sclerotherapy of gonadal veins is the treatment of choice for varicocele.

Percutaneous transluminal angioplasty (PTA) of supra-aortic arteries especially the internal carotid artery

We present our experience with 105 patients in whom percutaneous transluminal angioplasty was performed in 112 stenosed or occluded supra-aortic arteries. Symptoms of cerebrovascular and/or vertebrobasilar insufficiency were present in 104 of the 105 patients. The angioplasty was successful in 35 stenoses of the internal carotid artery, 2 stenoses of the common carotid artery, 1 stenosis of the external carotid artery, 15 stenoses of the vertebral artery, 3 stenoses of the innominate artery and 44 stenoses of the subclavian artery. There were only 4 minor-complications (2 haematomas, 1 transient ischemic attack, 1 small thrombus of the internal carotid artery which was detected by 111-indium platelet scintigraphy and treated by thrombendarterectomy before the appearance of neurological symptoms). All patients were symptom free after angioplasty. During the observations period of 3 to 109 months (average 58 months) there were only two cases with re-stenosis after subclavian angioplasty. The results of more than 700 personal and international published percutaneous transluminal angioplasties of supra-aortic arteries are presented. The results suggest that angioplasty of supra-aortic arteries is an effective method. On strict definition of the indications, the complication rate for angioplasty of the supra-aortic arteries is not likely to be higher than that for operative treatment.

High-dose-rate afterloading and the LQ-model--evaluation of efficacy in cervix cancer therapy

For short-time afterloading with high dose rates at irradiation treatment of gynecological tumors an adequate fractioning with reduced total dose is necessary considering the basically changed dose-time relation opposite to the common long-time brachytherapy. In addition to the careful clinical control of empiric found fractioning regimes for the primary and postoperative intrauterine and intravaginal afterloading therapy in cervix carcinoma and endometrium carcinoma, at which the surroundings reactions of the urine bladder, rectum and sheath, and also the tumor regression and relapses were investigated, a calculation of equivalent doses seems to be recommendable by means of mathematically formulated model conception according to the NSD formula and the LQ model. Changed exponents p for the fractioning rate N depending on the total treatments time were used for the rate calculations at slowly fractionated small-volume irradiation opposite to a higher fractionated percutaneous great-volume irradiation NSD conception was developed for. In LQ-model calculation changed coefficients mu for the repair half-life-time T in connection to the changed repair capacity in small volume brachytherapy were used. Knowing the compatibility and tumor efficiency of the rate-values and the alpha/beta-ratio for different fraction regimes were calculated and compared concerning their radiobiological equivalence and practical use. The calculations show a good clinical correspondence for single and total dosage in fractionated high dose rate afterloading of gynecological tumors.

[Early and late results after local streptokinase administration in massive lung embolism]

In a total number of 44 patients with acute massive lung embolism 42 patients survived the acute phase. The treatment was carried out by thrombolysis with streptokinase. The application was performed as near to the thrombus as possible, in several patients after preceding balloon dilatation or also as multiphase treatment using urokinase. We altogether obtained favourable early results concerning the recanalisation got as well as also with regard to the clinical state and the subjective condition, particularly for patients with single acute occurrence and a latency period of less than 72 hours up to the beginning of the treatment. In follow-up examinations of 17 patients after more than 9 months (on an average after 32 months) without exception a good and further on ameliorated condition, respectively, was stated. Under long-term anticoagulation with phenprocoumon no recidivation embolisms appeared. Ergooxytensiometric investigations had as result a clear to extreme hypoxia on exertion as limiting factor for 12 out of 17 patients. Apart from this the majority of the patients a hyperdynamic regulatation of the circulation was to be observed. Therefore the ergooxytensiometry is recommended for the judgment of the result of the treatment as to the demandable exercise tolerance.

Percutaneous transluminal angioplasty (dilatation) of carotid, vertebral, and innominate artery stenoses

Over a period of 5 years, 51 stenoses of brachiocephalic arteries were successfully dilated, and one subclavian occlusion recanalized in 42 patients. Among 24 patients there were 21 stenoses of the internal carotid artery, two stenoses of the common carotid artery, two stenoses of the innominate artery, five stenoses at the origin of the vertebral artery, and four stenoses of the subclavian artery. There were 17 patients who had stenoses of the subclavian artery. In 12 cases several arteries were affected. In 9 patients multiple (2-3) stenoses in these supraaortic arteries were dilated. In 4 cases bilateral dilatation of internal carotid arteries was performed. There were transient, minor complications in 2 patients.

[Late arterial complications after radiotherapy]

Late effects of radiotherapy are observed more frequently due to the improved results of the treatment of cancer and the resulting longer survival times. The big arteries, however, are only seldom attacked by late complications. The authors present a single case and stress the importance corresponding therapeutic action.

[Combination of arterial and venous vascular diseases]

The coincidence of arterial and venous vascular diseases in the region of the extremities is demonstrated. The frequency and the pathophysiological connections are explained and a subdivision of the different forms of combination is made. The therapy has to orient itself at the pathophysiological processes of the individual case, where the arterial as well as the venous vascular region is to be included in the treatment.

[Clinical and angiographic appearance of traumatic peripheral arteriovenous fistula]

Issuing from 33 patients with traumatic peripheral arteriovenous fistulas on the basis of an impressive case is reported on pathophysiological changes and it is referred to a possibly early operative correction of these peripheral arteriovenous shunt connections.

[Hemodynamic examinations concerning the effects of cardiac glycosides in hypertrophic obstructive cardiomyopathy (HOCM)]

Due to fundamental considerations and especially after Braunwald's et al. (1962 (4)) examinations of 5 patients with severe hypertrophic obstructive cardiomyopathy (HOCM) with 0.5-0.75 mg of Ouabain, cardiac glycosides in cases of this disease are to be regarded as contraindicated. Own examinations (right and left-heart catheterizations, monoplane cineangiography of the left ventricle, determination of the cardiac output, and the ejection fraction (EF) were performed in 10 patients with HOCM of different stages. Applying the usual dosage of 0.25-0.375 mg of strophanthin, different hemodynamic effects were observed in discrete forms. In cases with a higher severity, the observations of Braunwald et al. could actually be confirmed. The left ventricular systolic pressure gradients were increased, but cardiac output, left ventricular enddiastolic pressure, pulmonary pressure and resistance, and also arterial pressure and peripheral resistance behaved differently. EF increased slightly. The right infundibular gradients were decreased with one exception, or resp., they were unchanged. Obviously, HOCM reacts especially unfavourably with so-called left-ventricular cavity obliteration. The main importance might belong to the behaviour of the free lumen of the left ventricle. In regard of the principally reserved attitude towards the cardiac glycoside therapy in HOCM, no change has occurred. Only in patients with atrial fibrillation and a rapid heart rate, a therapy trial could be considered, if necessary in combination with beta-blocking agents or calcium antagonists under hemodynamic control. In cases of HOCM with serious obstruction and signs of cardiac failure and inadequate affecting by calcium antagonists, an early surgical intervention should be executed.

[Percutaneous transluminal angioplasty (PTA) of branches of the aortic arch (author's transl)]

The authors give a report on their first results of percutaneous transluminal angioplasty of aortic arch branches in 4 patients. In 3 cases, stenosis of left subclavian arteries were treated by PTA with good result. One patient had a stenosis of both carotid arteries which were dilated with moderate effect. In all patients symptoms were removed. There were no complications.