Schiffl, Helmut

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H. Schiffl

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Fibrinogen Apheresis and Peripheral Vascular Disease: Some Progress?

Open Access LMU ( Ludwig-Maximilians-Univ. München)

Fax +41 61 306 12 34E-Mail karger@karger.chwww.karger.com Letter to the Editor  Blood Purif 2007;25:515–516  DOI: 10.1159/000113084 resulted in a more pronounced depletion of fibrinogen levels (up to 70%) than a sin-gle session. Both whole blood and plasma viscosity were significantly improved by repeated aphereses. During combined fi-brinogen apheresis and specialized multi-modal wound care 3 out of 4 patients showed improved wound healing. After termination of apheresis 1 patient under-went surgery for diabetic foot syndrome. These effects of selective fibrinogen aphe-resis on microvascular haemodynamics may relate not only to sustained lowering of fibrinogen, but also to sustained reduc-tion in the levels of low-density lipoprotein cholesterol, C-reactive protein and adhe-sion molecules. There is an urgent need for prospective randomized investigations with selective fibrinogen apheresis in diseases with al-tered microvascular haemodynamics to corroborate the potential beneficial acute or short-term effects observed in small pilot studies. Moreover, prospective compari-sons of this apheresis device with non-se- Sir, Ramunni et al. [1] showed that a single session of selective fibrinogen apheresis reduced circulating fibrinogen by 50%. They  failed to document significant chang-es in microvascular haemodynamics by  laser Doppler flowmetry in their patients affected by various stages of peripheral  occlusive arterial disease. Of clinical rele-vance, symptomatic improvement was im-pressive, with both total and pain-free walking distance increasing significantly. Short-term improvement in delayed wound healing, another clinical symptom of severe impairment of microcirculation, has been reported for few patients with di-abetic foot syndrome or patients with isch-emic skin lesions  [2] . Our group performed repetitive treatments with selective fibrin-ogen adsorption (TheraSorb Technology, Plasma Select AG, Teterow, Germany) for 4 weeks in 4 diabetic patients  [3] . Treat-ments were scheduled on days 1, 2, 4, 6, 8, 10, 13, 16, 19, 22, 25, and 28. No clinical side effects of the procedure were observed during 46 sessions. Multiple treatments  Published online: January 14, 2008  Prof. Dr. H. Schiff l  University of Munich, Department of Internal Medicine   Ziemssenstrasse 1  DE–80336 Munich (Germany)  Tel. +49 89 5160 8397, Fax +49 89 5705 727, E-Mail hschiff l@hotmail.com  © 2008 S. Karger AG, Basel0253–5068/07/0256–0515$23.50/0  Accessible online at:www.karger.com/bpu lective plasma exchange or low-density li-poprotein apheresis are lacking. This places considerable constraints on a more wide-spread application of the costly and time-consuming selective fibrinogen aphe resis. Fibrinogen Apheresis and PeripheralVascular Disease: Some Progress?Helmut Schiffl University of Munich, Department of Internal Medicine, Munich, Germany References  1 Ramunni A, Brescia P, Quaranta D, Plan-tamura M, Ria R, Coratelli P: Fibrinogen apheresis in the treatment of peripheral arte-rial disease. Blood Purif 2007; 25: 404–410.  2 Richter WO, Schneidewind JM, Ramlow W, Jahn P, Jung N, Koll R, Klinkmann J: Extra-corporeal fibrinogen adsorption – Efficacy, selectivity and safety in healthy subjects and patients with foot ulcers. Transfus Apher Sci 2002; 26: 15–27.  3 Hierl FX, Petersen A, Landgraf R, Schiffl H, Spannagl M: First results of selective fibrino-gen elimination by Rheosorb absorbers in the treatment of the diabetic foot syndrome. Int Symp ‘Fibrinogen as a determinant of blood flow properties. Safety and efficacy of fibrinogen lowering with the RheoSorb sys-tem’, Berlin, January 2000.   Letter to the Editor Blood Purif 2007;25:515–516516 Sir, I agree with the author of the letter on the necessity of carrying out multicenter studies, numerically suitable, with the ob-jective of confirming the efficiency of apheresis procedures in the treatment of microcirculation disorders. However, I do not think that the use of highly selective apheresis, such as fibrino-gen apheresis, should be considered an ex-pensive or time-consuming event. On the contrary, the possibility of withdrawing specific molecules from the bloodstream allows for the capacity to investigate the pathological process at the base of the vas-cular damage, which is certainly preclud-ed from the plasma exchange, whose com-plete absence of selectivity in the elimina-tion of substances does not provide any useful information on the matter. In our article, to which the author of the letter  refers, our aim has been to investigate, among other factors, some markers of the endothelial activation. One possibility in this sense also de-rives from double filtration plasmaphere-sis, a semi-selective procedure to use and compare with decidedly selective aphere-sis in the treatment of peripheral arterial disease. Only the comparison betweenthe efficiency of low-density lipoprotein apheresis and fibrinogen apheresis on the one hand and double filtration plasma- Reply  Alfonso Ramunni  Division of Nephrology, Department of Internal and Public Medicine, University of Bari, Bari, Italy pheresis on the other will allow us to better understand the pathogenesis of microcir-culation disturbances, helping us to choose the most efficient procedure for the treat-ment of our patients. In this view, the methodologies of selective apheresis, be-sides the strategies of a therapeutic ap-proach, are to be considered real laborato-ries of in vivo investigation, which help us to understand the role of individual mol-ecules in the development of vascular pa-thologies. Consequently, instead of being dismissed for the costs or workload, they should be used on a greater scale, with the objective of clarifying their correct utiliza-tion. 

Coratelli P: Fibrinogen apheresis in the treatment of peripheral arterial disease. Blood Purif

Extracorporeal fibrinogen adsorption – Efficacy, selectivity and safety in healthy subjects and patients with foot ulcers. Transfus Apher Sci

Int Symp ‘Fibrinogen as a determinant of blood flow properties. Safety and efficacy of fibrinogen lowering with the RheoSorb system’,

Fibrinogen Apheresis and peripheral vascular disease: Some progress?

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Fibrinogen Apheresis and peripheral vascular disease: Some progress?

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