Surgical management of critical limb ischaemia in the French West Indies

This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age ñ SEM:73 ñ 15 yrs) admitted for critical limb ischaemia. 145 (84 percent) had tissue loss at admission: toe gangrene or ischaemic ulcer in 77, and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularisation were performed at iliofemoral (n = 20), suprapopliteal (n = 22) or infrapopliteal level. The postoperative mortality rate was 14 percent in the "Amputation" group and 9 percent in the "Revascularisation" group but the difference was not statistically significant. Infective complications were comparable in both groups, although 5 to 14 deaths after amputation were directly related to infection and all deaths after revascularisation resulted from cardiovascular complications. The early limb salvage rate after revascularisation was 82 percent. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p < 0.03) and had significantly higher rates of heart disease and nonambulatory status (respectively, 24 vs 17 percent, p < 0.05; and 37 vs 13 percent, p < 0.001) than patients in whom revascularisation was performed. Ischaemic rest pain and tissue loss confined to digit gangrene or ischaemic ulcer occurred more frequently than extensive gangrene in the "Revascularisation" group (p < 0.0001), while extensive gangrene extending beyond the forefoot occurred more frequently than ischaemic rest pain and tissue loss in the "Amputation" group (p < 0.0001). Late presentation of patients and enhanced tissue loss are probably the reasons for the higher primary amputation rate in our patients compared to that observed elsewhere. In patients amenable to revascularisation (56 percent), arterial reconstruction for critical limb ischaemia improves the chances of limb salvage.(AU)

Surgical management of critical limb ischaemia in Guadeloupe, French West Indies - abstract

This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age, 71 ñ 15 years) admitted for critical limb ischemia. 145 (84 percent) had tissue loss at admission including toe gangrene or ischemic ulcer in 77 and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularizations were performed at iliofemoral (n=20), suprapopliteal (n=22) or infrapopliteal level. Postoperative mortality rate was not significantly different in the "Amputation" group (14 percent) and "Revascularizations" groups 9 percent. Infective complications were comparable in both groups although 5/14 deaths after amputations were were directly related to infections while all deaths after revascularizations resulted from cardiovascular complications. The early limb salvage after revascularizations was 82 percent. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p<0.03) and with significantly higher rates of heart diseases and non-ambulatory status (respectively 24 vs 17 percent, p<0.05 and 37 vs 13 percent, p<0.001) than patients in whom revascularizations were performed. The major findings were that ischemic rest pain and tissue loss confined to digit gangrene or ischemic ulcer were significantly more frequent in the group "Revascularizations" (p<0.0001), while extensive gangrene extending beyond the forefoot (p<0.0001) was significantly more frequent in group "Amputations". Therefore, late presentation of patients and enhanced tissue loss are very likely to play a role in our primary amputation rate, higher than those observed elsewhere. In patients amenable to revascularizations (56 percent), arterial reconstructiions for critical limb icshemia performed in the West Indies provide for a fair likelihood of limb salvage. (AU)

Infrapopliteal bypass for critical limb ischaemia: early experience in the French West Indies

From December 1992 to October 1995, 42 infrapopliteal arterial bypass operations for limb salvage were performed in 39 patients (including 22 diabetics) with limb ischaemia (mean age, 71 years). Thirty-four patients (87 percent) had tissue loss at admission (8 ulcers, 13 digit gangrenes and 13 extensive foot infections). Angiographic findings were consistent with artherosclerotic involvement of femroal and crural arteries. Outflow anastomic sites were the popliteal (n = 5); tibial (n = 14); peroneal (n = 14) and pedal artery (n = 9). Autogenous saphenous vein was suitable in 27 procedures and inadequate in 15 (<3 mm diameter, with gross fibrosis or segmental occlusion) requiring prosthetic or composite grafts. Postoperative mortality rate was 10 percent, related to concomitant cardiovascular diseases. Mean follow-up was 14 months (range, 3 - 35). Fourteen bypasses failed, 5 in the early period (8 - 30 days) and 9 within a mean interval of 7.6 months, resulting in 6 limb amputations. Overall life-table primary graft patency rates were 72 percent (ñ 8) at 12 months and 61 percent (ñ 9) at 2 years and were not significantly different in diabetic patients compared to those in non-diabetics. Primary graft patency rates were significantly lower in prosthetic or composite grafts compared to saphenous vein grafts (75 percent vs 32 percent at 2 years - p<0.01), respectively. Overall life-table limb salvage rates were 84 percent (ñ 7) and 76 percent (ñ 9) at 12 and 24 months respectively. Seventy-eight percent of patients with limb salvage were relieved of ischaemic symptoms, 57 percent regained the ability to ambulate with improved functional level and 85 percent of tissue loss healed within a mean interval of 55 days. Infrapopliteal bypass operations for critical limb ischaemia performed in Martinique provide a fair chance of limb salvage despite limitations of medical facilities. (AU)

Infrapopliteal and distal bypass for limb salvage - abstract

Because the majority of our patients with lower limb ischemia present with femora popliteal disease, bypass surgery must be done to tibial and distal vessels for limb salvage. In 71 such bypasses done on 66 patients the indications were gangrene, 41, non healing ulcer 12, rest pain 18. Sixty-six bypasses were in situ saphenous vein while five were reversed vein grafts. Fourteen bypasses were done to the ankle or distally (5 dorsalis pedis, 7 posterior tibial, 2 plantar) while 57 were carried to infrapopliteal leg vessels (35 peroneal, 14 posterior tibial, 6 anterior tibial, 3 tibio-peroneal trunk). In the ankle/distal group 1 bypass occluded and 1 limb was lost. In the tibial group 8 bypasses occluded and 7 limbs were amputated. Although bypasses to the tibial and foot vessels are technically more demanding, they do carry a good limb salvage rate and patients should be given the benefit of this treatment (AU)

Foot ischaemia - a need for early rehabilitation

Ischaemia of the foot usually affects the elderly. The correlative study based on clinical data and pathological study has shown that maturity onset, diabetic foot ischaemia is usually due to severe arteriosclerosis. Because of the late presentation, most patients show end-stage obliterative vascular changes when first hospitalized which makes reconstructive surgery impossible. By early referral of all diabetic patients with infection, the number of below-knee or above-knee amputations can be reduced. Early prosthetic fitting is essential for the early rehabilitation of the patient. This paper was presented in part at the Commonwealth Caribbean Medical Research Council Meeting held at Bridgetown, Barbados in April, 1978. (AU)

The management of an aortic aneurysm involving the renal arteries

A case is presented in which both renal arteries were implanted during aortic aneurysmectomy without protection of the kidneys from 'warm' ischaemia. Despite at least 55 minutes of ischaemia, the kidneys functioned well immediately after (AU)

Photocoagulation and diathermy in the treatment of proliferative sickle retinopathy

The O'Malley Log II portable photocoagulator was used to treat the worse eye of 36 patients with proliferative sickle cell retinopathy flat on the retinal surface. The technique involved direct coagulation of the feeder arterioles before treatment of the new vessels themselves. The photocoagulator was most successful in treating the lesions and 131 of 137 retinitis proliferans (RP) lesions were occluded. In only one RP lesion did the photocoagulator have insufficient power to occlude the lesion. Vitreous haemorrhage occurred in only one patient and small round localized retinal haemorrhages in five. The Manchester portable diathermy machine successfully occluded all 29 raised RP lesions and fifty feeder arterioles in thirteen patients. Anterior segment ischaemia occurred in only one patient who had advanced traction retinopathy involving 360 degrees of arc of the retinal circumference before treatment. No recurrence of retinopathy over a 2-year follow-up period was seen in seven patients and in the remainder there was no recurrence in the 2 months after treatment. (Summary)

Ocular findings in children with sickle cell haemoglobin C disease in Jamaica

The ophthalmological findings in 54 Jamaican children with SC disease are reported. Evidence of peripheral retinal vessel disease was present in 94 percent and retinitis proliferans in 11 percent. Retinitis proliferans was noted as early as 7 years of age and was more common in patients with high haemoglobin levels. There was an unequivocal progression in severity of retinopathy in eight out of eleven children examined 2 years previously. The pathological processes leading to sickle cell proliferative retinopathy are well established in childhood and attempts at prophylactic therapy should be instituted at an early age. (Summary)

Facial palsy: a multifactorial entity

Facial Palsy is not a common condition in Kingston, Jamaica, only 21 cases being treated at the Kingston Hospital between 1958 and 1968. Statistical problems arise as a result of sampling distortion consequent on omission from the diagnotic records because of other overwhelming conditions, no attention being sought for the condition, or the patient being lost to follow-up. The age range is wide. Men were more commonly affected than women and at an older average age. A seasonal incidence has been demonstrated, some 71 percent (15/21) of the cases occurring in the warm season of the year (April to October). Older patients are more commonly affected during the warm months, raising the possibility of a vacular ischaemic process. Other aetiological factors such as exposure to cold, infections of viral or non-viral type, diabetes, and trauma are discussed. Trauma accounting for some 20 percent (4/21) of the cases seemed a particularly high percentage in this Jamaican series. The recovery rate in those followed up was favourable. Onset in summer and early spring appeared to exert a favourable prognostic effect (Summary)

Malabsorption and protein-losing enteropathy following small gut ischemia

This is a case reported of a 41-year-old male who was first seen at the University College Hospital with an incarcerated inguinal hernia. At herniorraphy, the suspiciously gangrenous segment of gut was not resected. Six weeks later the patient returned to hospital with severe weight loss, and symptoms and signs of intestinal obstruction. There was radiological, biochemical and haematological evidence of malabsorption and severe protein losing enteropathy. The patient made a complete recovery after surgical resection of the affected segment of gut (AU)

Influence of pregnancy and oral contraception on the incidence of strokes in women of childbearing age

Ischaemic strokes are not uncommon in women aged 15-45. Over 500 carotid strokes were fully investigated between 1956 and 1965; 146 (29.2 percent) of the patients were aged 15-45 and 44.5 percent of these were women. Since oral contraceptives became available the proportion of non-pregnant women among the cases investigated in this age group has not increased; 40 of the 42 non-pregnant women with strokes are known not to have been taking oral contraceptives. There is no obvious difference between strokes reported in association with oral contraceptives and those occuring in other women in this age-group; thus there is no evidence from this study that oral contraceptives are responsible for producing or precipitating cerebral arterial occulusion in young women. Of the 65 women with strokes, in this age-group a third were pregnant of puerperal; these pregnant patients had a considerably higher mortality than men or non-pregnant women women with strokes. Full investigation of cases of non-haemorrhagic hemiplegia in pregnancy shows that two-thirds are due to major arterial occlusion, and that cerebral venous thrombosis is not the usual cause, as is commonly stated. (AU)