Sympathectomy in the treatment of chronic venous leg ulcers.

Patients with recurrent, intractable postphlebitic ulcer were treated by using sympathectomy as an adjunctive procedure. After standardized aggressive conservative therapy and 47 prior operations, including skin grafts, local excision, and various localized and extensive vein ligations and/or strippings, 23 patients continued to have ulcerations for 11 months to thirteen years. After sympathectomy, all ulcers healed within two to 6 1/2 months. During a follow-up of 2 1/2 to 11 years, 18 patients remained free of ulcers. Four had recurrent ulcerations, three promptly healing with reinstitution of elastic support, which had been discontinued. Sympathectomy is a simple and effective adjunctive method of surgical management for the occasional patient with intractable recurrent postphlebitis ulceration.

Carotid endarterectomy for cerebrovascular insufficiency: long-term results in 592 patients followed up to thirteen years.

Seven hundred forty-eight carotid endarterectomies were performed on 592 patients with cerebrovascular insufficiency during a 13-year period. Overall operative procedure mortality was 2.7%. In the last 6 years, using a shunt routinely and avoiding operation on acute strokes, mortality was 1.47%. In frank strokes it was 3.7%; in transient ischemia, 0.77%; and zero for chronic ischemia and asymptomatic bruits. Incidence of operation-related deficits among transient ischemia and asymptomatic bruit patients was 0.9% for transient weakness and 2% for permanent deficits. Of 172 long-term deaths, 23 were due to cerebral causes, or 3.9% of the entire series. Among frank stroke survivors, 30.2% are normal and 58.7% improved. In transient ischemia survivors 81% are normal and 15.7% improved. In 65 asymptomatic bruit patients operated upon electively, two had strokes during follow-up, one mild and one severe. Among 37 asymptomatic bruit control patients, 24 or 65% developed symptoms of transient ischemia or frank strokes. Of 118 totally occluded carotid arteries explored, flow was restored in 48 (40.7%) but could not be restored in 70 (59.3%). For cerebral protection during carotid endarterectomy the routine use of a temporary inlying bypass shunt with general anesthesia is advocated for all partial occlusions. Endarterectomy is most useful for transient ischemia and selected patients with mild frank strokes and asymptomatic bruits. Acute profound and rapidly progressing strokes should not be operated upon as an emergency, but allowed to stabilize for several weeks and then be considered for possible operation.

Management of post-traumatic pain syndromes (causalgia).

A number of post-traumatic pain syndromes may be grouped under the two headings: causalgia and mimocausalgia states. Our concern is the early recognition of patients whose complaints have a real organic basis but whose physical signs are not of sufficient degree to make this fact readily apparent. These patients are all too often mismanaged or neglected for sufficiently long periods of time to permit the underlying pathologic physiology to secure supremacy over normal function. Recognized and treated properly by means of sympathetic ablation, either medical or surgical, the vast majority can be relieved of their symptoms. The extremities can then be rehabilitated by appropriate measures.

Management of asymptomatic carotid bruits.

Asymptomatic carotid bruits may originate in the internal carotid artery from atherosclerotic plaques which predispose to strokes in certain individuals over the age of 40. Certain recently developed noninvasive screening tests are helpful in determining the hemodynamic significance of these bruits, which ultimately require arteriography to determine precise diagnosis and significance. If hazardous lesions are demonstrated, carotid endarterectomy may be recommended for selected patients without multiple risk factors to prevent the occurrence of ischemic cerebral episodes.

Post-traumatic pain syndromes.

A number of post-traumatic pain syndromes may be grouped as causalgia or mimocausalgia. These are important entities and should be well known to most disciples of medicine. Our concern is the early recognition of patients whose complaints have an organic basis but whose physical signs are not of sufficient degree to make this fact readily apparent. These patients are often misunderstood and discredited. They are all too often mismanaged or neglected for so long that the underlying pathologic physiology secures supremacy over normal function. Recognized and treated properly by means of sympathetic ablation, either medical or surgical, the vast majority of symptoms can be relieved. The extremities then can be rehabilitated by appropriate measures.

Compartmental syndromes in peripheral vascular surgery.

The need to relieve muscle swelling and secondary vascular impairment of an extremity may occur following a variety of conditions. Regardless of the type of insult, massive swelling of an extremity can result in ischemic necrosis of muscle as a result of tamponade produced by restrictive circulferential fascia. When intracompartmental pressure approaches or exceeds arterial pressure, a portion or the entire extremity may be in jeopardy. Fasciotomy is one of the most important adjunctive procedures available to assure survival of an extremity with altered distal circulation resulting from massive swelling. Its importance has been stressed infrequently in the literature. The indications for its use are outlined in a variety of clinical situations. The proper techniques have few complications and much to offer with regard to limb salvage and reduction of morbidity. Fasciotomy does not preclude correction of the underlying cause for restrictive muscle tamponade when possible, nor can it be expected to reverse well established ischemia. Early and liberal use of fasciotomy is advocated when the outlined indications prevail.

Asymptomatic carotid bruit: long term outcome of patients having endarterectomy compared with unoperated controls.

During 20 years (1957-1977), 1286 carotid endarterectomies were performed on 1022 private patients with cerebrovascular insufficiency. Included were 132 patients undergoing 167 endarterectomies for asymptomatic cervical carotid bruits. Ages ranged from 42 to 82 years (mean: 64.7). Operative mortality was zero. There were two transient and two permanent operation-related neurologic deficits. Complete follow-up was achieved, extending to 184 months. During postoperative follow-up, six patients (4.5%) developed TIA's appropriate to the unoperated artery, three patients had strokes (2.3%), and three patients died of strokes (2.3%). To characterize the natural history of asymptomatic bruit and determine proper indications for prophylactic endarterectomy, a control series of 138 additional patients with asymptomatic bruit not operated upon when the bruit was discovered was studied. Ages ranged from 39 to 86 years (mean: 65.7). During follow-up extending to 180 months, 77 patients (55.8%) remained neurologically asymptomatic, 37 patients (26.8%) developed TIA's one month to 99 months after detection of bruit, and 24 patients (17.4%) sustained mild to profound frank strokes one week to 124 months postdetection. Three of these 24 (2.2%) died of stroke. Asymptomatic carotid bruits may be potential stroke hazards, the risk of which can be significantly reduced by appropriately applied endarterectomy. A protocol for managment is presented.

Acute arterial occlusions.

We believe that streptokinase is safe and effective in restoring the patency of arteries that have been acutely occluded by thrombosis or embolization. It should be used on those patients in whom the branches as well as the main conduits are occluded. It should also be used when the risks of surgery are great because of concurrent medical problems. Streptokinase should not be used after major surgery, in patients with blood dyscrasias, or when there are neurologic deficits secondary to the arterial ischemia. Streptokinase should not be considered as an antagonist to arterial surgery with the use of the Fogarty catheter but as an adjunct to the ever increasing armamentarium of the vascular surgeon.

Surgical management of abdominal aortic aneurysms: factors influencing mortality and morbidity--a 20-year experience.

Abdominal aortic aneurysmectomy is being performed with progressively lower operative mortality and morbidity. Three hundred thirty seven patients have had elective aneurysm repair since 1954. Factors affecting mortality and morbidity in the last 108 cases are analyzed. Seventy-four per cent of patients had pre-existing disease, either cardiac, pulmonary, renal, cerebrovascular, diabetes mellitus, or hypertension. Six patients died following operation, a mortality rate of 5.5%. One died of pulmonary and 5 of cardiac causes. No patient died of renal failure or required dialysis. A signficant feature of management is the regimen of fluid therapy using dextrose in lactated Ringer's solution during and after operation to minimize hypotensive and renal complications. No patient developed a wound infection, graft infection, wound dehiscence, stroke, or intestinal ischemia. Serious postoperative complications were largely cardiac or pulmonary. Despite recent liberalization of indications for operation, comparative figures show continued reduction in operative mortality from 17% during 1954-1961, or 7.4% during 1962-1967, to 5.5% in the 1968-1974 era. This declining mortality is related to earlier diagnosis using non-invasive methods (sonogram), simplified operative techniques, improvement in fluid management, innovations in cardiopulmonary therapy, and recognition and proper handling of unusual manifestations of aortic aneurysms.

Mesenteric vascular problems. A 26-year experience.

Mesenteric vascular problems are infrequent, but may be catastrophic. During a 26-year period, 55 private patients were treated for the following disorders: (1) 12 patients with visceral artery aneurysms, (2) 8 with celiac compression syndrome, (3) 13 with chronic mesenteric ischemia, (4) 12 with acute mesenteric ischemia, and (5) 10 with mesenteric ischemia associated with aortic reconstructions. Splenic artery aneurysms were managed by excision and splenectomy, while celiac and hepatic had excision with graft replacement. Patients with celiac compression syndrome underwent lysis of the celiac artery. Two patients had compression of both celiac and superior mesenteric artery (SMA). One patient required vascular reconstruction of both arteries for residual stenoses. Patients having chronic mesenteric ischemia were treated with bypass grafts, with one death (7.7% mortality) and good long-term results. Those with acute mesenteric ischemia were treated by SMA embolectomy, bowel resection, or both, with a mortality of 67%. When associated with aortic reconstructions, mesenteric ischemia carried a mortality of 100% if bowel infarction occurred after operation, but when prophylactic mesenteric revascularization was performed at the time of aortic surgery, prognosis was greatly improved, with only one death among six patients. An aggressive approach including prompt arteriography with early diagnosis and surgical therapy is advocated for these catastrophic acute mesenteric problems.