Factors influencing ulcer healing in patients with combined arterial and venous insufficiency.

PURPOSE: The purpose of this study was to determine the effectiveness of treatment of patients with combined arterial and venous insufficiency (CAVI), evaluate variables associated with successful ulcer healing, and better define criteria for interventional therapy. STUDY DESIGN: We retrospectively reviewed the records of patients treated at four institutions from 1995 to 2000 with lower extremity ulcers and CAVI. Arterial disease was defined as an ankle/brachial index less than 0.9, absent pedal pulse, and at least one in-line arterial stenosis > 50% by arteriography. Venous insufficiency was defined as characteristic clinical findings and duplex findings of either reflux or thrombus in the deep or superficial system. Clinical, demographic, and hemodynamic parameters were statistically analyzed with multiple regression analysis and correlated with ulcer healing and limb salvage. RESULTS: Fifty-nine patients with CAVI were treated for nonhealing ulcers that had been present from 1 to 39 months (mean, 6.4 months). All patients had edema. The mean ankle/brachial index was 0.55 (range, 0-0.86). Treatment included elastic compression and leg elevation in all patients and greater saphenous vein stripping in patients with superficial venous reflux. Fifty-two patients underwent arterial bypass grafting, three underwent an endarterectomy, one underwent superficial femoral artery percutaneous transluminal angioplasty, and three underwent primary below-knee amputation. For purposes of analysis, patients were divided into four groups according to the pattern of arterial and venous disease and the success of arterial reconstruction. Group 1 consisted of 22 patients with a patent arterial graft, superficial venous incompetence, and normal deep veins. Group 2 consisted of seven patients with a patent graft, superficial reflux, and deep venous reflux. Group 3 included 22 patients with a patent graft and deep venous thrombosis (DVT), and group 4 included eight patients with an occluded arterial graft. Follow-up ranged from 2 to 47 months (mean, 21.6 months). Forty-nine patients remained alive, and 10 died of unrelated causes. During follow-up, 48 of the 56 treated arteries remained patent and eight occluded. Thirty-four ulcers (58%) healed, 18 ulcers (31%) did not heal, and 7 patients (12%) required below-knee amputation for nonhealed ulcers and uncontrolled infection. No patient with graft occlusion was healed, and 12 ulcers persisted despite successful arterial reconstruction. Twenty-one (78%) of 27 patients undergoing greater saphenous vein stripping were healed, but none of these patients had DVT. The mean interval from bypass graft to healing was 7.9 months. Thirty-two (68%) of 46 patients without prior DVT were healed, whereas only two (15%) of 13 patients with prior DVT were healed, and this variable, in addition to graft patency, was the only factor statistically significant in predicting healing (P <.05). CONCLUSIONS: Ulcers may develop anywhere on the calf or foot in patients with CAVI, and healing requires correction of arterial insufficiency. Patients with prior DVT are unlikely to heal, even with a patent bypass graft. Ulcer healing is a lengthy process and requires aggressive treatment of edema and infection, and successful arterial reconstruction. Patients with a prior DVT are unlikely to benefit from aggressive arterial or venous reconstruction.

Wound infections involving infrainguinal autogenous vein grafts: a current evaluation of factors determining successful graft preservation.

PURPOSE: The purpose of this study was to review the natural history and clinical outcome of patients with infrainguinal autogenous graft infection (IAGI), to evaluate the effectiveness of attempted graft preservation, to determine those variables associated with graft salvage, and to better determine optimal treatment. STUDY DESIGN: We retrospectively reviewed the records of patients undergoing infrageniculate vein grafts at three hospitals between 1994 and 2000 who had a wound infection involving the graft. Clinical and bacteriologic variables were analyzed and correlated with graft salvage, limb salvage, and clinical outcome. RESULTS: During this 7-year period, 487 patients underwent an infrageniculate vein graft, and 68 (13%) had clinical evidence of IAGI. Twenty-seven patients presented with drainage from the wound, 15 with wound separation and cellulitis, 18 with soft tissue infection extending to the graft, 4 with an abscess and cellulitis, and 4 with bleeding. Ten patients (15%) had systemic symptoms (defined as a white blood cell count > 15,000 and temperature > 38.5 degrees C). Forty infections developed in the thigh, 17 in the groin, and 11 in the lower leg. An anastomosis was exposed in 15 patients. Wound cultures were positive for bacteria in 52 patients, and most infections were due to Staphylococcus aureus (18 patients) and S epidermidis (12 patients). Pseudomonas was cultured from seven infections. Twelve patients had polymicrobial infections. The interval from operation to infection ranged from 7 to 180 days. All patients were treated with oral antibiotics, 48 after intravenous antibiotics. Forty-five patients had operative debridement, including 18 who had muscle flap coverage. Four patients presented with hemorrhage, and three had immediate graft ligation and one graft excision. Follow-up ranged from 5 to 68 months (mean, 24.3 months), with 61 patients currently alive. Two patients died as a result of the IAGI (mortality rate, 2.9%). One had undergone a below-knee amputation, and one had a nonhealed wound but intact limb. Overall, 61 wounds (91%) healed, 4 patients required below-knee amputations, and 3 wounds did not heal. Fifty-eight grafts remained patent, 6 thrombosed, and 4 were ligated to control hemorrhage. Of the 61 wounds that healed, the time required for healing ranged from 7 to 63 days. No patient with bleeding died because of the acute episode. No patient had delayed hemorrhage. All 18 patients treated with a muscle flap healed. Bleeding (P <.001), elevated white blood cell count (P <.029), fever (P <.001), and renal insufficiency (creatinine level > 1.5; P <.056) were the only variables statistically significant in predicting graft failure or limb loss. With the use of life-table analysis, graft patency was 94%, 72%, and 72% at 1, 3, and 5 years, and limb salvage was 97%, 92%, and 92% at the same intervals, respectively. CONCLUSIONS: Most patients with an IAGI can be successfully treated with graft and limb preservation. In contrast to earlier studies, an exposed anastomosis, interval to infection, or Pseudomonas infection is not associated with graft failure. Graft salvage is less likely in patinets with fever, leukocytosis, and renal insufficency, but because most grafts remained patent, graft preservation is recommended for these patients. Graft ligation or excision should be reserved for patients presenting with bleeding or sepsis.

Cervical vascular injuries: carotid and jugular venous injuries.

This article explores the management of carotid arterial injuries, detailing the historical evolution for the management of these injuries and delineating techniques for cerebral perfusion and preservation with shunts. It discusses the role of autogenous versus synthetic grafts in the management of these injuries and the issue of vascular complications and potential pitfalls. Jugular venous injuries are addressed also, with emphasis on the controversies of primary repair versus ligation.

Comparison of intravenous/oral ciprofloxacin plus metronidazole versus piperacillin/tazobactam in the treatment of complicated intraabdominal infections.

OBJECTIVE: To compare the safety and efficacy of intravenous (IV) ciprofloxacin plus IV metronidazole (CIP+MET) with that of IV piperacillin/tazobactam (PIP/TAZO) in adults with complicated intraabdominal infections, and to compare the efficacy of sequential IV-to-oral CIP+MET therapy with that of the IV CIP-only regimen. SUMMARY BACKGROUND DATA: Treatment of intraabdominal infections remains a challenge, mainly because of their polymicrobial etiology and attendant death and complications. Antimicrobial regimens using sequential IV-to-oral therapy may reduce the length of hospital stay. METHODS: In this multicenter, randomized, double-blind trial involving 459 patients, clinically improved IV-treated patients were switched to oral therapy after 48 hours. Overall clinical response was the primary efficacy measurement. RESULTS: A total of 282 patients (151 CIP+MET, 131 PIP/TAZO) were valid for efficacy. Of these patients, 64% CIP+MET and 57% PIP/TAZO patients were considered candidates for oral therapy. Patients had a mean APACHE II score of 9.6. The most common diagnoses were appendicitis (33%), other intraabdominal infection (29%), and abscess (25%). Overall clinical resolution rates were statistically superior for CIP+MET (74%) compared with PIP/TAZO (63%). Corresponding rates in the subgroup suitable for oral therapy were 85% for CIP+MET and 70% for PIP/TAZO. Postsurgical wound infection rates were significantly lower in CIP+MET (11%) versus PIP/TAZO patients (19%). Mean length of stay was 14 days for CIP+MET and 17 days for PIP/TAZO patients. CONCLUSION: CIP+MET, initially administered IV and followed by CIP+MET oral therapy, was clinically more effective than IV PIP/TAZO for the treatment of patients with complicated intraabdominal infections.

In vitro activities of nontraditional antimicrobials against multiresistant Acinetobacter baumannii strains isolated in an intensive care unit outbreak.

Fifteen multiresistant Acinetobacter baumannii isolates from patients in intensive care units and 14 nonoutbreak strains were tested to determine in vitro activities of nontraditional antimicrobials, including cefepime, meropenem, netilmicin, azithromycin, doxycycline, rifampin, sulbactam, and trovafloxacin. The latter five drugs were further tested against four of the strains for bactericidal or bacteriostatic activity by performing kill-curve studies at 0.5, 1, 2, and 4 times their MICs. In addition, novel combinations of drugs with sulbactam were examined for synergistic interactions by using a checkerboard configuration. MICs at which 90% of the isolates tested were inhibited for antimicrobials showing activity against the multiresistant A. baumannii strains were as follows (in parentheses): doxycycline (1 microg/ml), azithromycin (4 microg/ml), netilmicin (1 microg/ml), rifampin (8 microg/ml), polymyxin (0.8 U/ml), meropenem (4 microg/ml), trovafloxacin (4 microg/ml), and sulbactam (8 microg/ml). In the kill-curve studies, azithromycin and rifampin were rapidly bactericidal while sulbactam was more slowly bactericidal. Trovafloxacin and doxycycline were bacteriostatic. None of the antimicrobials tested were bactericidal against all strains tested. The synergy studies demonstrated that the combinations of sulbactam with azithromycin, rifampin, doxycycline, or trovafloxacin were generally additive or indifferent.

Determinants of survival after inferior vena cava trauma.

Inferior vena cava (IVC) injuries continue to be associated with mortality rates of 21 to 66 per cent despite advances in prehospital, surgical, and critical care. The purpose of this study was to evaluate outcome of patients with IVC injury after treatment at a major urban trauma center and to identify factors predictive of survival. Between 1989 and 1995, 158 patients presented to the Los Angeles County + University of Southern California Medical Center with IVC injuries. One hundred thirty-six patient records were available for review, and 69 data points were collected and analyzed. Mean age was 26 years (range, 6-54), and 122 (90%) patients were male. Mechanism of injury included gunshot in 88 (65%) patients, stab in 23 (17%) patients, shotgun in 7 (5%) patients, and blunt trauma in 18 (13%) patients. The mean Injury Severity Score was 25. Seventy (52%) patients were hypotensive. Eleven (8%) patients died before surgical intervention, and 25 (18%) patients died before operative repair. Repair (79), ligation (20), or observation (1) was accomplished in 100 (74%) patients. Overall survival was 48 per cent and 65 per cent in the 100 patients surviving to operative repair, including 5 of 20 patients requiring IVC ligation. Significant differences (P<0.001) between survivors and nonsurvivors included Injury Severity Score, Glasgow Coma Score, hematocrit, hypotension, emergent thoracotomy, blood loss, level of injury, tamponade, and associated aortic injury. Logistic regression analysis identified hypotension, anatomic level of injury, and associated aortic injury as significant predictors of outcome (P = 0.001). Survival is predominantly determined by severity and anatomic accessibility of the IVC injury and by the absence of associated major vascular injuries. Ligation may control otherwise exsanguinating injuries and should be considered early in the management of complex injuries.

Combined carotid endarterectomy and coronary artery bypass grafting in asymptomatic carotid artery stenosis.

The role of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) in patients with severe asymptomatic carotid artery disease and concurrent symptomatic coronary artery disease is controversial. The objective of this report is to investigate the safety of combined CEA/CABG. The medical records of 30 patients who underwent combined CEA/CABG for coexistent asymptomatic carotid and symptomatic coronary artery occlusive disease were reviewed. All patients were scheduled for either elective or urgent myocardial revascularization due to their symptomatic coronary artery disease. Color-flow duplex scanning identified internal carotid artery stenosis of 80 to 99 per cent in 28 patients (93%) and 50 to 79 per cent in 2 patients (7%). Seventeen patients (57%) were male. The mean age was 64 +/- 10 years (range, 42-84 years). Contralateral internal carotid artery occlusion was present in four patients. Severe left main coronary artery disease was present in 12 patients (40%) and 7 patients (23%) had an ejection fraction of less than 50 per cent. There were no perioperative deaths or strokes. One patient suffered a myocardial infarction on postoperative day 1. This study demonstrates the safety of combined CEA/CABG for coexistent coronary and asymptomatic carotid disease. Using this surgical approach for critical coexistent disease may minimize the incidence of perioperative cerebrovascular complications in patients undergoing CABG.

Effective lipid modification by partial ileal bypass reduced long-term coronary heart disease mortality and morbidity: five-year posttrial follow-up report from the POSCH. Program on the Surgical Control of the Hyperlipidemias.

BACKGROUND: In 1990, when the Program on the Surgical Control of the Hyperlipidemias (POSCH) reported its in-trial results strongly supporting the conclusion that effective lipid modification reduces progression of atherosclerosis, the differences for the end points of overall mortality and mortality from atherosclerotic coronary heart disease (ACHD) did not reach statistical significance. METHODS: The Program on the Surgical Control of the Hyperlipidemias recruited men and women with a single documented myocardial infarction between the ages of 30 and 64 years who had a plasma cholesterol level higher than 5.69 mmol/L (220 mg/dL) or higher than 5.17 mmol/L (200 mg/dL) if the low-density lipoprotein cholesterol level was in excess of 3.62 mmol/L (140 mg/dL). Between 1975 and 1983, 838 patients were randomized: 417 to the diet control group and 421 to the diet plus partial ileal bypass intervention group. Mean patient follow-up for this 5-year posttrial report was 14.7 years (range, 12.2-20 years). RESULTS: At 5 years after the trial, statistical significance was obtained for differences in overall mortality (P = .049) and mortality from ACHD (P = .03). Other POSCH end points included overall mortality (left ventricular ejection fraction > or =50%) (P = .01), mortality from ACHD (left ventricular ejection fraction > or =50%) (P = .05), mortality from ACHD and confirmed nonfatal myocardial infarction (P<.001), confirmed nonfatal myocardial infarction (P<.001), mortality from ACHD, confirmed and suspected myocardial infarction and unstable angina (P<.001), incidence of coronary artery bypass grafting or percutaneous transluminal coronary angioplasty (P<.001), and onset of clinical peripheral vascular disease (P = .02). There were no statistically significant differences between groups for cerebrovascular events, mortality from non-ACHD, and cancer. All POSCH patients have been available for follow-up. CONCLUSION: At 5 years after the trial, all POSCH mortality and atherosclerosis end points, including overall mortality and mortality from ACHD, demonstrated statistically significant differences between the study groups.

Diagnosis and management of penetrating vascular trauma and the injured extremity.

Early diagnosis and timely treatment of extremity vascular injuries are essential if limb salvage and limb function are to be optimized. Careful and repeated clinical examination and ankle/brachial doppler indices are pivotal for early diagnosis. Routine arteriography for proximity injury is neither cost effective nor clinically indicated and minimal non-occlusive arterial injuries do not require vascular repair. An algorithm for the diagnostic evaluation and treatment of patients with penetrating extremity trauma is presented. The early diagnosis of compartment syndrome is stressed.

Double-blind comparison of single-dose alatrofloxacin and cefotetan as prophylaxis of infection following elective colorectal surgery. Trovafloxacin Surgical Group.

BACKGROUND: Alatrofloxacin, the prodrug of trovafloxacin, is a novel fluoroquinolone antimicrobial agent with a broad spectrum, including activity against gram-positive and gram-negative aerobes and anaerobes. Its pharmacokinetic properties (long half-life, excellent tissue distribution, and good safety profile) suggest a role in surgical prophylaxis. This prospective, multicenter, double-blind trial compared alatrofloxacin with cefotetan, an approved drug for surgical prophylaxis, in reducing postoperative infections. METHODS: The efficacy and safety of a single 200-mg intravenous dose of alatrofloxacin were compared to a single 2-g intravenous dose of cefotetan in 492 patients undergoing elective colorectal surgery. The efficacy of alatrofloxacin as a prophylaxis for wound, intra-abdominal, or remote-site postoperative infectious complications was compared with cefotetan in 317 clinically evaluable patients; 161 received alatrofloxacin and 156 received cefotetan. The patients were monitored for infections and safety for 30 days postoperatively. RESULTS: No statistically significant between-treatment difference was detected in successful clinical response rates at the end of the study (72% for each group). The incidence of primary wound infections at the time of hospital discharge was also similar: 21% in patients treated with alatrofloxacin and 18% in those treated with cefotetan. Safety, established by the incidence of adverse events, did not differ statistically between the groups. CONCLUSIONS: A single intravenous dose of alatrofloxacin given within 4 hours prior to surgery was as effective as an intravenous dose of cefotetan in the prevention of postoperative infectious complications in patients undergoing elective colorectal surgery. The safety profiles of the two medications were similar.

Trovafloxacin in the treatment of intra-abdominal infections: results of a double-blind, multicenter comparison with imipenem/cilastatin. Trovafloxacin Surgical Group.

BACKGROUND: Trovafloxacin, a new broad-spectrum fourth-generation quinolone, has in vitro activity against most gram-negative and gram-positive anaerobes and aerobes. Trovafloxacin is available as both an intravenous formulation, alatrofloxacin, and a single daily oral tablet. Excellent tissue pharmacokinetics and oral bioavailability suggest usefulness in the treatment of complicated intra-abdominal infections. Thus, the efficacy of alatrofloxacin followed by oral trovafloxacin was compared with the standard regimen of intravenous imipenem/cilastatin followed by oral amoxicillin/clavulanic acid in this prospective, multicenter, double-blind trial. METHODS: Patients were randomized to receive either 300 mg alatrofloxacin daily followed by 200 mg oral trovafloxacin daily or 1 g imipenem/cilastatin intravenously thrice daily followed by 500 mg oral amoxicillin/clavulanic acid thrice daily for up to 14 days following surgical intervention of a documented intra-abdominal infection. Efficacy was assessed at the end of therapy and at follow-up (day 30). RESULTS: At the end of the study, cure or improvement occurred in 83% (129/156) and 84% (127/152) of clinically evaluable patients in the trovafloxacin and comparative groups, respectively. Pathogen eradication rates, adverse-event profiles, and significant laboratory abnormalities were comparable between groups. CONCLUSION: Intravenous alatrofloxacin with or without oral trovafloxacin was as effective as intravenous imipenem/cilastatin followed by oral amoxicillin/clavulanic acid in complicated intra-abdominal infections.

Changing perspectives in the diagnosis of peripheral vascular trauma.

The diagnosis of peripheral vascular trauma has undergone significant evolution in the last two decades. A minority of patients with arterial trauma present with classic findings that make the diagnosis obvious. However, the diagnosis of occult arterial injuries is more challenging, and it is for this group that the diagnostic algorithm has changed most significantly. Because of the low yield of routine operative exploration and routine arteriography to evaluate potential injury to vessels in proximity to penetrating wounds, many authors now recommend the selective use of arteriography or other diagnostic modalities based on the results of clinical examination and noninvasive pressure determinations. This article reviews the evidence in support of such a selective approach to the diagnosis of arterial injuries.

Vascular complications of thoracic outlet syndrome.

Vascular complications of thoracic outlet syndrome are uncommon but may result in significant long-term disability. This report documents a retrospective review of 17 such patients. Ten patients presented with acute onset of upper extremity swelling and axillosubclavian vein thrombosis. One patient presented with chronic, intermittent arm swelling and subclavian vein stenosis. Three patients presented with acute symptoms of upper extremity emboli, and three presented with chronic arm claudication. Cervical ribs were discovered in four patients with arterial symptoms and in no patients with venous symptoms. All ten patients with acute venous thrombosis underwent successful thrombolysis, with venous stenosis uncovered in 8. Thrombolysis was also performed for two patients with arterial emboli. All 17 patients underwent surgical decompression of the thoracic outlet, 16 via a supraclavicular approach and one via a transaxillary approach. One subclavian arteriotomy with endarterectomy and one resection of a subclavian artery aneurysm were performed at the time of decompression. Repeat venography after decompression demonstrated persistent venous stenosis in one patient that was treated with balloon angioplasty and stenting. After a mean of 22 months' follow-up, 12 patients had no residual symptoms, and 5 had experienced significant improvement of symptoms. In conclusion, a combined approach of thrombolysis and surgical decompression of the thoracic outlet provides a salutary outcome in a majority of patients.

Relationship between intraoperative color-flow duplex findings and early restenosis after carotid endarterectomy: a preliminary report.

PURPOSE: This study was undertaken to examine the relationship between intraoperative color-flow duplex (CFD) findings and the development of restenosis in patients undergoing carotid endarterectomy (CEA). METHODS: Seventy-eight patients (43 male and 35 female; mean age, 65 years) underwent 86 CEAs (eight staged bilateral) and intraoperative CFD during a 31-month period. Three patients (three CEAs, 3%) underwent both CFD and a completion arteriographic scan. Patients were observed in a postoperative protocol using CFD surveillance. The follow-up interval ranged from 6 to 24 months (average, 12 months). RESULTS: After undergoing CEA, 10 patients (10 CEAs, 11%) had an abnormality detected by intraoperative CFD; one was confirmed with a completion arteriographic scan. These abnormalities consisted of elevated peak systolic velocities (PSV) with a mosaic color pattern suggesting turbulence seen in six CEAs, including one internal carotid artery (ICA) with abnormal hemodynamics and an unremarkable completion arteriogram. Intimal defects on B-mode were seen in another four CEAs. These carotid arteries were reexplored, defects (intimal flaps with platelet thrombus) were confirmed by direct examination, and all were repaired with or without a patch (six ICAs, three external carotid arteries, and one common carotid artery). No cerebrovascular events occurred in the perioperative period. No carotid restenosis (> or = 50% diameter reduction) was identified during follow-up of 43 patients (48 CEAs, 56%). Two patients had recurrent neurologic symptoms. CONCLUSION: Intraoperative CFD is an effective test for detecting flow abnormalities or intimal defects in patients undergoing CEA. Ensuring normal intraoperative hemodynamics after CEA may be a major factor associated with decreased incidence of perioperative cerebrovascular events and subsequent carotid artery restenosis.

Penetrating trauma of the internal carotid artery.

OBJECTIVE: To assess management of penetrating internal carotid artery (ICA) injuries. DESIGN: Retrospective review of institutional protocol. SETTING: Level 1 trauma center in a major urban area. PATIENTS: Sixty-one patients with penetrating ICA injuries. INTERVENTIONS: In the period 1975 to 1987 (group 1; n = 36), management was based on individual surgeons' preferences. Between 1988 and 1995 (group 2; n = 25), an algorithm was employed: (1) hemodynamically stable patients with suspected ICA injuries underwent a diagnostic angiography; (2) surgically accessible injuries were reconstructed regardless of neurologic status with 2 exceptions: (a) neurologically intact patients with ICA occlusion were treated by anticoagulation and mild pharmacological hypertension and (b) minimal nonocclusive injuries were managed nonoperatively and followed up by serial angiography or duplex ultrasonography; and (3) heparinization, shunting, and completion angiography were employed. MAIN OUTCOME MEASURES: Neurologic status at admission and discharge were compared by the Fisher exact test. RESULTS: In group 1, 24 patients (67%) presented neurologically intact, and 12 (33%) with a deficit. Sixteen injuries were managed nonoperatively, 14 were repaired, and 6 were ligated. At discharge 6 (17%) were improved, 24 (66%) were unchanged, 6 (17%) were worse. Four patients (11%) died of cerebrovascular causes. In group 2, 19 patients (76%) presented neurologically intact, and 6 (24%) with a deficit. Eleven injuries were managed nonoperatively, 12 were repaired, and 2 were ligated. A death occurred in a patient who arrested, was admitted to the hospital in a coma, and died before ICA repair. CONCLUSIONS: Neurologic outcome after ICA injury is enhanced by an algorithm predicated on the liberal use of angiography, a predefined surgical approach, and selective observation.

Difficult peripheral vascular injuries.

Successful management of the difficult peripheral vascular injury requires a multidisciplinary approach. Prompt recognition of the vascular injury and adherence to the recognized principles of vascular repair provide a successful short-term surgical result. The long-term consequences of an injury are determined by the associated orthopedic, soft tissue, and nerve injuries.

Cardiac evaluation of the diabetic patient prior to peripheral vascular surgery.

The benefit of preoperative cardiac evaluation in the diabetic patient undergoing peripheral vascular surgery is uncertain. To investigate this issue we performed a retrospective review of 192 procedures performed in diabetic patients for chronic lower extremity arterial occlusive disease. The incidence of adverse postoperative cardiac events was determined, as well as its association with several preoperative factors including symptoms of coronary artery disease (CAD), extent and results of preoperative noninvasive cardiac evaluation, and operative site (aorta vs. lower extremity). The overall death and cardiac complication rates were 10.2% for lower extremity and 25.7% for aortic procedures (p = 0.02). For myocardial infarction and cardiac death alone, the rates were 5.1% and 5.7%, respectively (p > 0.10). Although a history of symptomatic CAD predicted the occurrence of any cardiac complication (28.3% vs. 8.2% [p < 0.01] for the aortic and lower extremity revascularization groups combined), no factor was found to be associated with the occurrence of myocardial infarction and cardiac death alone. In patients with a history of symptomatic CAD, there was no significant difference in the incidence of complications whether or not preoperative noninvasive cardiac testing was performed (28.1% vs. 28.6%, p > 0.10) or, if testing was performed, if the results were abnormal or normal (35.3% vs. 20.0%, p > 0.10). Similar results were obtained in patients with no history of symptomatic CAD. In summary, this retrospective review of our experience with noninvasive evaluation to detect CAD in diabetic patients undergoing peripheral vascular surgery failed to show any benefit in terms of reducing the incidence of postoperative cardiac events.

Intraoperative color duplex scanning for infrainguinal vein grafts.

We compared the findings of intraoperative color duplex scanning and completion arteriography in patients undergoing infrainguinal vein bypasses to identify hemodynamic abnormalities that could result in a predisposition to early or late graft failure. We reviewed the records of 72 patients who underwent 81 vein bypass graft procedures. Three intraoperative diagnostic methods were used. In 28 procedures (group I) both color duplex and completion arteriography were used, in 21 procedures (group II) only color duplex was used, and in 26 procedures (group III) only completion arteriography was used. Grafts were followed using a duplex surveillance protocol for a mean interval of 16.1 months. Nine grafts in group I showed an abnormality on the duplex scan but not on the completion arteriogram. Seven grafts had a peak systolic velocity (PSV) greater than 200 cm/sec and two had a PSV less than 45 cm/sec. These findings led to six immediate repairs, one early revision, and two late revisions. Arteriography demonstrated additional defects in two procedures but repairs were not performed. In group II duplex scans showed an abnormality in eight procedures (seven grafts with PSV 200 to 250 cm/sec and one graft with a retained valve) resulting in three immediate repairs and five late revisions. In the remaining 13 procedures in group II, duplex scans were normal and no revisions were required during follow-up. In group III defects were detected by arteriography in four procedures (> 50% stenosis in three grafts and one arterial spasm) leading to three immediate repairs. In the remaining 22 studies arteriograms were interpreted as normal; however, seven of these grafts required late revisions. Our data suggest that grafts that appear normal on intraoperative duplex scans are not likely to develop a stenosis requiring revision. Intraoperative duplex ultrasound may be superior to completion arteriography.

A prospective study of carbon dioxide-digital subtraction vs standard contrast arteriography in the evaluation of the renal arteries.

OBJECTIVE: To compare carbon dioxide-digital subtraction arteriographic (CO2-DSA) images of renal artery anatomy with standard iodinated contrast arteriographic (ICA) images. DESIGN: One hundred patients with vascular disease who required abdominal aortography were evaluated by both CO2-DSA and ICA modalities. Two blinded readers interpreted arteriograms for the degree of renal artery stenosis, and a third reader was employed to resolve differences in reader interpretations. SETTING: University medical center. MAIN OUTCOME MEASURES: The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy were calculated for the ability of CO2-DSA to demonstrate a 60% or greater stenosis of the main renal artery; kappa values for CO2-DSA and ICA were calculated to assess intraobserver variability. RESULTS: Of the 200 main renal arteries imaged, 17 (9 by means of CO2-DSA), 8 means of ICA) were eliminated because of inadequate visualization of the renal artery. In identifying a renal artery stenosis of 60% or greater, CO2-DSA had a sensitivity of 0.83, specificity of 0.99, positive predictive value of 0.94, and negative predictive value of 0.98. The overall accuracy was 0.97. The kappa was 0.75 for CO2-DSA and 0.70 for ICA, hence, the variation in the interpretations of CO2-DSA and ICA were comparable. CONCLUSION: Images by means of CO2-DSA accurately reflect pathologic changes in renal arteries and are thus useful in the diagnosis of clinically occult occlusive renal artery disease in patients at risk of contrast medium-related nephrotoxicity.