A review of one hundred forty-seven popliteal aneurysms with long-term follow-up.

A 20-year experience with a collected series of 147 popliteal aneurysm in 87 patients is reviewed; there were 84 male patients. Ages ranged from 42 to 90 years with a median age of 60.2. Bilateral aneurysms were found in 60 patients (68%). Ninety-eight extremities presented with symptoms, whereas 94 aneurysms had one or more preoperative complications. Sixty-six (45%) were thrombosed, 34 (23%) had embolized, and four (3%) had ruptured. Associated aneurysms were found in 55% of the total group and in 68% of those with bilateral popliteal aneurysms. Forty percent of all patients had abdominal aortic aneurysms, whereas 34% had femoral aneurysms and 25% had iliac aneurysms. Therapy included bypass grafting (99), observations (26), primary amputation (12), sympathectomy (3), and exploration only (7). In 32 limbs, grafts became occluded during the follow-up period. All except one of the occluded grafts were in patients with preoperative symptoms related to the aneurysm, and all but one primary form of therapy and 22 as a secondary procedure. All were associated with preoperative vascular ischemia or a complicated aneurysm. Complete, detailed, long-term follow-up of 1 to 14 years is reported for 65 patients. The overall follow-up averaged 44 months. Death rates were shown by life-table analysis to be significantly greater than rates among the general population. Complications of aneurysms were very common (64%) and when the occurred, 36% ended in amputation. Therefore, elective replacement of the aneurysm at the time of diagnosis is recommended.

Effect of a failed distal reconstruction on the level of amputation.

Controversy exists as to whether the level of amputation is adversely affected by an unsuccessful limb salvage attempt. Two hundred ten amputations following failed reconstruction attempts in 191 patients were studied and compared with 551 amputations in limbs with no prior revascularization. Initially, 147 of those with failed reconstruction attempts underwent below-knee (BK) amputation and 63 underwent above-knee (AK) amputation. One hundred ten of 143 (77%) surviving BK amputations eventually healed. This is in contrast to the eventual healing in 266 of 298 (89%) of the BK amputations performed with no prior attempts at reconstruction. A statistically significant (p less than 0.05) difference in eventual healing favoring those with no prior reconstruction was demonstrated. Successful reconstruction of the ischemic extremity is the goal of vascular surgery and should be attempted when indicated. However, it should be realized that unsuccessful revascularization attempts may adversely affect healing in those limbs initially considered for a BK amputation.

Rehabilitation of the bilateral amputee.

One hundred sixteen patients with bilateral amputation as a result of severe ischemia were reviewed to evaluate their rehabilitation potential. Seventy patients were male and 46 were female; ages ranged from 31 to 92 years (mean 68 years). The operative mortality rate after the second amputation was 9.5% (11 of 116 patients). The time from the first to second amputation ranged from zero to 144 months (mean 23 months). Follow-up from 1 to 14 years was available on all patients. Sixty percent of the patients surviving the postoperative period were alive at 2 years and 40% at 5 years. Of the 105 patients available for follow-up, only 27 (26%) were able to use bilateral prostheses. Twenty-three (85%) of these patients were ambulatory after their first amputation. Four patients not walking after their first amputation became ambulatory after their second. All four had bilateral below-knee amputations. Of the 78 patients unable to use a bilateral prosthesis, 68 (87%) were able to function independently and 10 became bedridden. Successful prosthetic rehabilitation in the bilateral amputee appears primarily dependent on the use of a prosthesis after the first amputation. The acceptable long-term survival and the number of patients who became independent in their activities justify an aggressive approach to the rehabilitation of the bilateral amputee.

Optimal cerebral monitoring during carotid endarterectomy: neurologic response under local anesthesia.

A prospective series of carotid endarterectomies were performed with patients given local anesthesia in an attempt to determine the efficacy of intraoperative EEG monitoring and/or stump pressure measurements in predicting the need for carotid shunting. Carotid artery stump pressure was measured and EEG changes noted; however, neither low stump pressure nor EEG changes influenced the decision for shunt insertion. A shunt was only used if a neurologic deficit developed during carotid clamping. A total of 134 carotid endarterectomies were done in 121 patients. Sixty-six patients were men and 55 were women with ages ranging from 41 to 88 years. Indications included transient ischemic attacks in 57 (43%), prior stroke in 25 (19%), vertebrobasilar symptoms in nine (6%), and asymptomatic patients with high-grade stenosis, 43 (32%). Thirteen patients (9.7%) developed neurologic deficits following carotid clamping and had shunts inserted. All deficits cleared following shunt insertion. Nine of the 13 had EEG changes, but in four, EEGs were unchanged despite the occurrence of clear-cut neurologic changes. Stump pressure in the 13 patients ranged from 14 to 78 mm Hg. Ten were greater than 24 mm Hg and three were more than 50 mm Hg. In 121 operations no neurologic deficits occurred during carotid clamping and no shunts were inserted. In 13 of these operations, significant EEG changes were noted. Stump pressures in these 13 with EEG changes ranged from 15 to 120 mm Hg. In seven, stump pressure was greater than 50 mm Hg. There were no deaths in the series. Two (1.5%) temporary and one (0.7%) permanent postoperative deficits occurred.(ABSTRACT TRUNCATED AT 250 WORDS)