Platelet aggregation in patients with peripheral vascular disease.

Platelet aggregation has been studied in 28 control subjects and 46 patients with peripheral vascular disease. The platelets from the patients with peripheral vascular disease were significantly more sensitive to the aggregating effects of adenosine diphosphate and adrenaline than those from the control group (P less than 0.001). In addition, spontaneous platelet aggregation was observed in vitro in several of the vascular patients; this response was not apparent in the control group. Increased platelet aggregation could add to the vascular impairment in the unoperated subject and might also play a part in premature graft failure. Platelet function studies should perhaps be included as a routine in the assessment of patients with peripheral vascular disease.

Thrombo-embolectomy and thrombolytic therapy in acute lower limb ischaemia. A five year experience.

Between 1988 and 1993, 82 patients with a median age (iq range) of 81 (73-87) years underwent thrombo-embolectomy (TE) and thrombolysis for acute lower limb ischaemia at the Royal Hallamshire Hospital, Sheffield. 28 patients (Group 1) underwent TE prior to the introduction of thrombolysis in 1991. TE with intraoperative thrombolysis (IT) as an adjunct was performed in 34 patients (Group 2) and 20 patients (Group 3) were treated using percutaneous thrombolysis (PT) in the first instance. 41 of these patients were in AF at presentation. Although 24 were on digoxin, only 4 were on warfarin. Group 3 patients were younger (p < 0.05; ANOVA) with a longer duration of ischaemia (p < 0.05; ANOVA) and had less limbs suffering a sensorimotor deficit (p = 0.007; chi 2) compared with Groups 1 and 2 which were similar in these respects. Overall mortality was 17%. Successful revascularisation was achieved in 18 (64%), 28 (82%) and 15 (75%) patients in Groups 1, 2 and 3 respectively. 14 of the 15 patients successfully treated initially by PT required further intervention in order to maintain revascularisation. Revascularisation failure was associated with the presence of a sensorimotor deficit but not associated with patient age or duration of ischaemia.

beta blockade and intermittent claudication: placebo controlled trial of atenolol and nifedipine and their combination.

OBJECTIVE: To determine the effects of the beta 1 selective adrenoceptor blocker atenolol, the dihydropyridine calcium antagonist nifedipine, and the combination of atenolol plus nifedipine on objective and subjective measures of walking performance and foot temperature in patients with intermittent claudication. DESIGN: Randomised controlled double blind four way crossover trial. SETTING: Royal Hallamshire Hospital, Sheffield. SUBJECTS: 49 patients (40 men) aged 39-70 with chronic stable intermittent claudication. INTERVENTIONS: Atenolol 50 mg twice daily; slow release nifedipine 20 mg twice daily; atenolol 50 mg plus slow release nifedipine 20 mg twice daily; placebo. Each treatment was given for four weeks with no washout interval between treatments. MAIN OUTCOME MEASURES: Claudication and walking distances on treadmill; skin temperature of feet as measured by thermistor and probe; blood pressure before and after exercise; subjective assessments of walking difficulty and foot coldness with visual analogue scales. RESULTS: Atenolol did not significantly alter claudication distance (mean change -6%; 95% confidence interval 1% to -13%), walking distance (-2%; 4% to -8%), or foot temperature. Nifedipine did not alter claudication distance (-4%; 3% to -11%), walking distance (-4%; 3% to -10%), or foot temperature. Atenolol plus nifedipine did not alter claudication distance but significantly reduced walking distance (-9%; -3% to -15% (p less than 0.003)) and skin temperature of the more affected foot (-1.1 degrees C; 0 to -2.2 degrees C (p = 0.05)). These effects on walking distance and foot temperature seemed unrelated to blood pressure changes. CONCLUSIONS: There was no evidence of adverse or beneficial effects of atenolol or nifedipine, when given singly, on peripheral vascular disease. The combined treatment, however, affected walking ability and foot temperature adversely. This may have been due to beta blockade plus reduced vascular resistance, which might also explain the reported adverse effects of pindolol and labetalol on claudication.

The long term results of profundaplasty in femoropopliteal arterial occlusion.

The long term results of profundaplasty in the treatment of femoropopliteal arterial occlusion have been reviewed. Fifty patients have been studied with a mean follow-up period of 4 years (range 6 months to 8 years). Intermittent claudication was abolished or substantially improved in 5 of the 25 cases (20 percent); rest pain was relieved in 10 of the 25 cases (40 per cent), the remainder requiring a major amputation. Lumbar sympathectomy produced little additional benefit in either group. The mortality rate in the rest pain group was high and only 5 patients survived for more than 3 years with both legs intact. The state of the distal 'run-off' and the degree of preoperative profunda stenosis appeared to have little influence on the clinical outcome. After operation pedal pulses were restored in 16 per cent of those presenting with claudication. Profundaplasty was without significant effect on the ankle systolic pressure index both in patients with claudication and those with rest pain.

Popliteal artery injury complicating arthroscopic meniscectomy.

We describe two patients who sustained serious vascular complications following arthroscopic lateral meniscectomy. Such injuries are rarely encountered or reported in the literature and, as such, the potential catastrophic sequelae of this particular complication of arthroscopy may be underestimated. Investigation of suspected popliteal artery injuries is outlined and the need for a high index of suspicion and early referral to a vascular surgeon is stressed.

Severe lower limb ischaemia with pulses: cholesterol embolisation--a little known complication of aortic surgery.

Cholesterol embolisation is a little known complication of aortic surgery and radiological procedures with a mortality of 81%. Treatment has been poorly described and inadequate. We report a case in which we have followed an aggressive policy of treatment using modern vascular techniques not previously described in this condition.

Gangrene of the toes with palpable peripheral pulses.

Thirty-five patients with gangrene or pregangrene of the feed associated with palpable peripheral pulses have been treated with the platelet suppressive drugs aspirin and dipyridamole. Sulphinpyrazone was substituted for two patients who could not tolerate aspirin. Complete reversal of the signs and symptoms occurred in more than 50% of the treated patients. Recurrence of pain occurred in the five patients in whom antiplatelet therapy was discontinued. Reversal of symptoms was again achieved by reintroduction of the drugs. An increased incidence of spontaneous platelet aggregation and hypersensitive platelets was observed in those patients who responded to platelet suppressive therapy. These results indicate that platelet suppressive therapy is of therapeutic value in selected patients with peripheral gangrene.

Surgery for limb threatening ischaemia: a reappraisal of the costs and benefits.

OBJECTIVES: To study the quality of life of patients following surgery for critical limb is ischaemia. DESIGN: Part retrospective, part prospective open study. SETTING: Vascular unit of a University Hospital. MATERIALS: Seventy-nine consecutive patients, medium age 75 years (range 44 to 94), who presented with leg threatening ischaemia and who underwent successful revascularisation or a major amputation were studied. CHIEF OUTCOME MEASURES: Six separate quality of life measures were recorded at 6 months: pain, mobility, anxiety, depression, activities of daily living (Barthel) and lifestyle (Frenchay). MAIN RESULTS: The mortality of this group of patients after six months was 24%. Forty-seven patients were available for quality of life assessment six months after initial intervention. Overall, amputation was more costly than successful revascularisation and limb salvage. Limb salvage resulted in greater mobility (p < 0.001) and better performance in self-care (p < 0.001) and lifestyle (p = 0.006), but produced more anxiety and depression (p = 0.04) than major amputation. A subgroup of patients who had major amputation after a failed limb salvage operation consumed a disproportionate amount of resources and, although their mobility was typical of amputees, their self-care and lifestyle scores were similar to those who had successful limb salvage. OBSTRUCTIONS: Limb salvage is attempted in up to 22% of patients for whom primary amputation may provide more expeditious rehabilitation with minimal impairment of their lifestyle performance.