Femoral pseudoaneurysm following nonpenetrating trauma in a patient with aortic insufficiency.

Although not uncommon after penetrating vascular trauma, arterial pseudoaneurysms rarely develop following blunt trauma. A patient is described in whom indirect trauma led to pseudoaneurysm of the profunda femoris artery, and persistent bleeding required surgical intervention. In this case, the coexistence of significant aortic valvular regurgitation suggests that wide pulse pressure may predispose to this arterial complication.

Tissue damage caused by the intramuscular injection of long-acting penicillin.

In order to elucidate whether tissue damage produced on occasion by intramuscular injection of long-acting penicillin is due to accidental intra-arterial injection or vasospasm, two types of experiments were carried out in rabbits. In the first set of experiments, six New Zealand White rabbits were given intra-arterial injections of 0.4 mL of a mixture containing 300,000 U of penicillin G benzathine and 300,000 units of penicillin procaine per milliliter (Bicillin C-R) into the left femoral artery and 0.4 mL of normal saline into the right femoral artery as autocontrol. In a second set of experiments, 0.4 mL of the same penicillin preparation was injected in the space surrounding the left femoral artery in five New Zealand rabbits, and 0.4 mL of normal saline was injected in a similar fashion around the right femoral artery as control. The legs of the rabbits that received the intra-arterial injection of penicillin invariably developed ischemic manifestations. None of the legs of rabbits given intra-arterial injections of normal saline had pathologic manifestations. None of the rabbits that received the periarterial penicillin preparation or normal saline developed abnormalities. These results strongly suggest that the tissue damage produced by penicillin is secondary to the intra-arterial administration of the drug.

Venous revascularization of the arm: report of three cases.

Three patients with disabling sequelae of venous obstruction in the upper extremity were treated surgically. In one, direct venous repair was used, whereas in the other two, the internal jugular vein was used to bypass the area of obstruction. Restoration of adequate venous return was associated with permanent symptomatic relief.

Necrotizing fasciitis of perineum.

Twenty-eight patients with necrotizing fasciitis of the perineum were treated at the Mount Sinai Medical Center from 1971 to 1979. Ten of the 28 died of the disease, for a mortality rate of 36%. The mortality rate was even higher when the lesion was located in the perianal area and associated with diabetes mellitus and delayed surgical intervention. Necrotizing fasciitis is a rare disease that involves both superficial and deep fascia. It begins with fascial necrosis at onset and rapidly progresses to surrounding fascial planes, eventually involving overlying skin and underlying muscle. Evidence proves that it is not the result of abscess, but primarily originates from fascia and is devoid of frank pus in the well-formed pyogenic abscess cavity. If one observes dark brown necrotic turbid fluid and fails to see frank pus, the disease should be treated as necrotizing fasciitis by complete surgical removal of all necrotic tissue until the normal plane is reached.

Reduced anastomotic bleeding using new sutures with a needle-suture diameter ratio of one.

Reduction of blood loss from a vascular anastomosis, especially when one is using a polytetrafluoroethylene (PTFE) graft, is of great interest; even when a technically perfect anastomosis has been performed, there can still be significant and often bothersome bleeding from the needle holes. Currently, sutures have a needle-to-suture ratio of 2:1 or 3:1. Two new sutures, one made of PTFE and the other of polypropylene, were designed to have a needle-to-suture diameter ratio of 1:1. Theoretically, this allows the suture to completely fill the graft needle hole and control bleeding. These sutures were evaluated in a heparin-treated canine in vivo model to measure graft needle-hole bleeding. The materials were also tested by an independent laboratory to compare the basic physical characteristics. Twenty centimeters of 6 mm PTFE graft was interposed in an end-to-end fashion to the infrarenal canine aorta. The graft was then transected at its midpoint and a series of end-to-end, graft-to-graft anastomoses were performed with alternate experimental and control sutures. The experimental PTFE suture bled a mean of 12.46 ml per anastomosis. The experimental polypropylene bled 4.32 ml per anastomosis, while a control suture of polypropelene with a needle-to-suture ratio of 1.94 (5-0 prolene with a C-1 needle), produced a mean blood loss of 33.35 ml per anastomosis. These data are based on a total of 82 anastomoses. The results were analyzed with a two-tailed paired t test. As the data indicate, both experimental sutures allowed significantly less bleeding than the controls (p = .05). The testing of physical properties of the suture included diameter, tensile strength, needle pull-off strength, and elongation percent and were performed by an independent laboratory. These findings are included along with subjective evaluations of the sutures' handling qualities. We believe that sutures produced with needle-to-suture ratios of 1:1 greatly reduce graft needle-hole bleeding and will be a useful addition to the vascular surgeon's armamentarium.

Description of a universal data entry and retrieval program for vascular surgeons.

Until recently, vascular surgeons have had to make judgments based on an impression of their experiences rather than upon the actual facts. Presently, with the simplified and less costly use of computers, the establishment of a computerized data base is feasible. Our goal had been to develop a system suitable for micro- or minicomputers which can be programmed in ordinary English and, once in place, requires essentially no knowledge of computers or computer programming for its successful use. Such a data base could put to an end the comparison of series that are truly incomparable because of differences in data classification and presentation. For example, in the case of a femoropopliteal bypass, which eventuates in a successful thrombectomy, some call it a success, some call it a failure, and some list it as both a success and failure. Many ignore the thrombectomy entirely and choose to place the final result in the plus category of "limb salvage." One seemingly insurmountable problem has been that because practice patterns differ, it has been necessary to design individual computer programs. A programmer has been required to write each of these programs, with consequent great expense and delay. While there are programs available for establishing a data base, they largely have required the use of large computers. Using such a computer implies a time sharing system with frustrations in regard to both availability and ease of use.

The expanded polytetrafluoroethylene graft. Three years' experience with 362 grafts.

A total of 362 polytetrafluoroethylene (PTFE) grafts were implanted in patients as vascular substitutes in a variety of vascular reconstructive procedures. A total of 184 were used in femoropopliteal bypass operations. Cumulative patency rates showed 74% patency at the end of the first year of observation and 58% after two and three years. Seventeen grafts were used for femorotibial bypasses, with a cumulative patency rate of 40.4% after one year. Ninety-eight grafts were implanted in the upper or lower extremity to serve as vascular access for hemodialysis. For this group, the cumulative one-year patency rate was 83%. Sixty-three additional grafts were implanted in various other anatomic locations. Based on this experience, the PTFE graft seems to be a promising and versatile vascular prosthesis, although it should be used cautiously.

Application of visually evoked response near the threshold of vision to objective measurement of dark adaptation.

The visually evoked response (VER) to dim lights with intensities within the scotopic or lower mesopic range increased in amplitude during the progressive dark adaptation. The VER amplitude vs. time curve resembled the psychophysical dark adaptation curve. The spectral sensitivity curve of the dark-adapted VER matched the C.I.E. scotopic sensitivity curve. The dark-adapted VER was abnormal in patients with retinitis pigmentosa and with congenital stationary night blindness and recordable in a patient with cone dysfunction. There was a close correlation between the VER threshold and subjective threshold of visual perception. The dark-adapted VER may be useful as an objective index of dark adaptation.

Evaluation of axillo-axillary artery bypass for the treatment of subclavian or innominate artery occlusive disease.

Because of the higher morbidity and mortality of transthoracic procedures, extrathoracic techniques to revascularize the subclavian or innominate artery, such as carotid subclavian and axillo-axillary artery bypasses have gained wide acceptance. The present work evaluates the results of axillo-axillary bypass in 33 patients who underwent this procedure in the past 13 years. There were 13 males and 20 females with a mean age of 61 years. The occlusive disease was present in the subclavian artery in 19 patients and in the right subclavian artery in 14 patients. Eleven patients presented with central nervous system symptoms and 10 patients complained of ischemic arm symptoms. The remaining 12 patients had both central neurological and upper extremity complaints. Twenty-one of these patients were followed for up to 5 years (mean follow-up 21 months). One patient died during the procedure from myocardial infarction (mortality of 3.03%). Patency of the bypass was determined by palpation of the graft pulse, doppler examination, and brachial arterial pressure determination. The patency rate, after 5 years, calculated by life table analysis, was 72%. In conclusion, axillo-axillary artery bypass can provide durable relief of symptoms with an acceptably high patency rate and low morbidity and mortality. It is the technique of choice in high-risk patients.

Aorto-caval fistula: a clinical spectrum.

Ten cases of aortocaval fistula (ACF) associated with abdominal aortic aneurysm (AAA) were reviewed. In 5 cases the ACF became apparent after evacuation of the thrombus; only 5 patients presented with features of patent ACF. Four patients in addition presented with extra-caval rupture of the aneurysm. Based on these variables, a classification relating ACF and AAA was developed. In this series all patients were male with a mean aneurysm size of 8.5 cm. All patients required bifurcation grafts for reconstruction. A multifactorial etiology related to enlargement and rupture of all aneurysms seems to apply to ACF. Eight of 10 patients survived. Awareness of this entity and proper preparation allow for successful outcome in the treatment of this condition.