Mobilization of fluids in large volumetric reductions during intensive treatment of leg lymphedema.

AIM: The aim of the current study was to evaluate fluid mobilization during the intensive treatment of leg lymphedema. METHODS: The mobilization of intracellular and extracellular fluids in the lower and upper extremities and trunk was evaluated with the intensive treatment of leg lymphedema in a prospective study. Mobilization of fluids was assessed by bioelectrical impedance using the InBody S10 device in ten patients with leg lymphedema, regardless of the cause. Treatment consisted of six to eight hours per day of Manual Lymphatic Therapy (Godoy & Godoy technique), Mechanical Lymphatic Therapy (RAGodoy device®) and a non-elastic cotton-polyester stocking. RESULTS AND CONCLUSION: A significant reduction in total water was observed for the lymphedematous limb, but with an increase in intracellular water of from 59% to 61%. Additionally, total water increases were observed in the limbs without lymphedema and in the trunk. There was an increase in total intracellular water of the extremities and trunk, but without any change in the extracellular water. In high-volume reductions during lymphedema treatment, fluids are displaced from the lymphedematous limb to extremities without lymphedema and to the trunk.

Progression of reflux patterns in saphenous veins of women with chronic venous valvular insufficiency.

BACKGROUND: Venous ultrasonography identifies reflux patterns of the great and small saphenous veins (GSV, SSV), allowing evaluation of lower extremities for treatment planning and patient follow-up. OBJECTIVE: To determine progression of saphenous vein reflux patterns in women with primary venous valvular insufficiency. METHODS: Venous ultrasonography was performed in the extremities of 92 women, 43 ± 12 (23-77) years old, CEAP (clinical, aetiological, anatomical and pathological elements) clinical classes C1-C2. Two examinations were performed 33 ± 19 (8-89) months apart in patients without saphenous vein treatment. GSV and SSV reflux patterns were classified as segmental, multisegmental, distal, proximal, diffuse and normal. Prevalence was determined for each examination, separately for right and left extremities, and jointly. Prevalence was compared using χ2 statistics. RESULTS: Reflux prevalence was higher for the GSV, 89% (164/184) and 88% (n = 162), than for the SSV, 24% (n = 45) and 30% (n = 56), respectively for first and second examinations (P < 0.001). Reflux pattern prevalence was not significantly different in the right and left extremities (1.0 > P > 0.14). Most prevalent patterns were (a) GSV segmental reflux initially, 41% (76/184), decreasing to 28% (52/184) (P = 0.009), and (b) GSV multisegmental reflux at the second examination, increasing from 26% (48/184) to 40% (73/184) (P = 0.006). Prevalence of other GSV or SSV reflux patterns did not change significantly (0.88 > P > 0.19). CONCLUSIONS: We documented early findings and venous reflux progression in a specific population of women with varicose veins, reticular veins and telangiectasias. GSV segmental reflux was most prevalent initially, progressing to GSV multisegmental reflux.

Assessment of venous thrombus time of progression by gray-scale median analysis.

AIM: To determine if gray-scale median (GSM) analysis could differentiate acute and recent deep venous thrombosis (DVT). METHODS: Patients submitted to vascular ultrasound examination of lower extremities due to suspected DVT were evaluated. Patients with acute or recent femoropopliteal DVT were included, whereas those without DVT, with chronic or isolated calf DVT were excluded. Time of onset of DVT symptoms was recorded. A transverse image of the thrombosed vein and adjacent artery was obtained. Two sonographers determined a subjective impression of thrombus time of progression and classified it as acute or recent. Thrombus GSM was calculated with a software. ROC curve was used to determine GSM cut-off points. Fischer's exact and Student´s t tests were also used. P<0.05 indicated statistical significance. RESULTS: 128 veins of 63 extremities were studied. Thrombus GSM correlated with time of onset of DVT symptoms (P=0.005) and with subjective evaluation of thrombus time of progression (P<0.001). When DVT symptoms had begun up to two weeks before and thrombus was classified as acute, GSM was lower. Area under ROC curve for thrombus GSM was 0.76 (P<0.001). GSM 17.90, 23.03, and 40.02 cut-off points differentiated between acute and recent thrombi with 35.59% sensitivity and 91.30% specificity, 59.32% sensitivity and 84.06% specificity, 91.53% sensitivity and 31.88% specificity, respectively. CONCLUSION: GSM was a reliable tool for objectively differentiating acute and recent DVT in most thrombus images. GSM 17.90 and 40.02 cut-off points showed high specificity and high sensitivity, respectively, for acute and recent DVT differentiation. In 17.90 to 40.02 interval, GSM cut-off point that best distinguished acute from recent DVT was 23.03.

Does the number of pregnancies affect patterns of great saphenous vein reflux in women with varicose veins?

OBJECTIVES: Impact of pregnancies on great saphenous vein (GSV) reflux patterns deserves clarification. Which GSV segment is most affected? Is the saphenofemoral junction (SFJ) involved? METHODS: Colour-flow duplex ultrasonography was performed in 583 women extremities with primary varicose veins (clinical, aetiological, anatomical and pathological elements [CEAP C2]), without oedema, skin changes or ulcer. Women with previous thrombosis or varicose surgery were excluded. GSV reflux sources and drainage points were located at SFJ, thigh, knee and calf. Prevalence of most proximal reflux source was noted as a function of 0, 1, 2, 3 and 4 or more pregnancies. chi(2) statistics was employed. RESULTS: Prevalence of GSV reflux was not dependent on 0, 1, 2, 3 or >or=4 pregnancies: 75%, 69%, 79%, 70% and 76% for right leg (P = 0.79) and 78%, 81%, 82%, 79% and 73% for left leg (P = 0.87), respectively. Prevalence of SFJ reflux and GSV reflux, starting at the thigh, knee or calf, was similar and showed no tendencies to increase with number of pregnancies. CONCLUSIONS: Number of pregnancies did not influence GSV reflux patterns in women with primary varicose veins.

Incidence of side effects using carbon dioxide-oxygen foam for chemical ablation of superficial veins of the lower extremity.

OBJECTIVES: To determine the incidence of side effects following treatment of varicose veins with carbon dioxide-oxygen (CO(2)/O(2)) foam sclerotherapy, and to compare results with historical controls using CO(2)- or air-based foams. DESIGN: Cohort study with prospective data collection, private clinic setting. PATIENTS: The patient population consisted of one hundred patients, 95% women, age 52 SD 13 years-old, CEAP class C(2)EpAsPr. METHODS: Patients underwent ultrasound-guided foam sclerotherapy following thermal ablation of saphenous trunks; 1-3% polidocanol and 70%CO(2)-30%O(2) gas were mixed in a 1:4 proportion. Volume injected averaged 22 SD 11 (range: 2-46) mL. Vital signs were monitored for 1 h; side effects were recorded up to 24 h post treatment. Incidence of side effects was compared to CO(2)- and air-based foam data. RESULTS: Heart rate decreased from 73 SD 11 at the start to 68 SD 9 bpm (p < 0.001, paired t-test) following the procedure. Systolic and diastolic pressures, 127/75 SD 18/14 mmHg, respiratory rate, 15 SD 4 rpm and pO(2), 98 SD 2%, did not change significantly. Itching (7) or leg pain (24) reporting was similar to that for air-based foam (p = NS). Lack of reported chest tightness and/or dry cough was superior to our previous data with CO(2) or air foam (p < 0.05). Reporting of dizziness (1) was less than that for air-based foam (p = 0.002). The incidence of visual disturbance (2%), was comparable with that for CO(2) (3%) or air (8%) foam, but too few cases were available for meaningful statistical analysis. CONCLUSIONS: Foam sclerotherapy using CO(2)/O(2) foam was well tolerated by patients and resulted in fewer side effects than similar treatment using air foams.

Femoral pseudoaneurysm thrombinjection.

BACKGROUND: The risk of pseudoaneurysm (PSA) increases with the number of catheterizations performed for cardiovascular diagnosis and therapy. Thrombin injection, or "thrombinjection," is an alternative to ultrasound-guided compression or surgical repair. Thrombinjection is effective and economical, but the specter of systemic arterial thrombosis hinders its wide application. We report cautionary steps taken prior to injection and lessons learned during our first 20 cases. METHODS AND RESULTS: Thrombinjection was performed under ultrasound (US) guidance in 12 women and 8 men with PSA after femoral catheterization. PSA varied in size from 17 to 39 mm with neck openings from 1.5 to 3.9 mm. Under local anesthesia and US longitudinal view, a 20-gauge US needle tip was placed in the PSA away from the neck. With 12 cases under 600 units, 100 to 2,300 units of thrombin (1,000 U/mL) were injected slowly. Slow injection, positioning of the ball of thrombus formed at the needle tip, probe compression, and combined or interchangeable use of US color flow and B-mode were the essential techniques utilized. All PSA thrombosed successfully on the first treatment. One patient had fever and another returned for compression treatment of a second, not recurrent, PSA. CONCLUSIONS: Successful thrombinjection was accomplished by focusing on common femoral artery PSA with small neck openings, avoiding arteriovenous fistulas, and using standard thrombin concentration, US needle, state of the art ultrasonography, slow injection, thrombus ball positioning, and adjunctive probe compression.

Diameter-reflux relationship in perforating veins of patients with varicose veins.

PURPOSE: Treatment of chronic venous valvular insufficiency requires understanding of the hemodynamics of perforating veins. To preserve normal veins or veins that can function normally once primary sources of valvular insufficiency are removed, a better understanding of the diameter-reflux relationship is desirable. We measured reflux and diameters in 500 perforating veins of patients with varicose veins (C(2)E(P)A(SP)P(R)). METHODS: Color flow duplex ultrasonography scanning was performed with the patient standing. Perforating veins were mapped medially in the thigh and medially, laterally, and posteriorly in the calf. Reflux was defined as reverse flow that lasted longer than 0.5 seconds. Diameters were measured on B-mode transverse projections at the crossing of the fascia. Competent versus incompetent vein diameters were compared by means of Student t test, one-way analysis of variance, and Bonferroni t test. RESULTS: Diameters of competent and incompetent perforators averaged 2.5 +/- 0.9 mm (n = 17) and 4.7 +/- 1.9 mm (n = 17) at the medial thigh (P <.0002), 2.2 +/- 0.8 mm (n = 179) and 3.7 +/- 1.0 mm (n = 210) at the medial calf (P <.0001), 2.2 +/- 0.6 mm (n = 13) and 3.5 +/- 0.8 mm (n = 37) at the posterior calf (P <. 0001), and 2.1 +/- 0.8 mm (n = 9) and 3.3 +/- 0.7 mm (n = 18) at the lateral calf (P <.003), respectively. Perforating vein diameters of 3.5 mm or larger in the calf and thigh were associated with reflux in more than 90% of the cases. CONCLUSION: An enlargement in the diameter of the perforating veins of 1 to 1.5 mm in the calf or 2 mm in the thigh of patients with varicose veins could be the difference between normal flow and reflux. Further studies are needed to confirm if elimination of reflux in patients with primary varicosity will transform incompetent perforators to competent ones.

Carotid arterial ultrasound scan imaging: A direct approach to stenosis measurement.

PURPOSE: Management decisions regarding carotid artery disease are critically dependent on stenosis but have been made difficult because of conflicting methods used to determine such stenosis. The increasing use of duplex ultrasound scanning has conventionally depended on Doppler velocity measurement, an indirect method for calculating carotid stenosis. Recent technical advances have improved the quality of B-mode/color-flow ultrasound scan imaging (USI). We tested prospectively whether USI was clinically effective as the primary criterion for estimating carotid stenosis. METHODS: Transverse and longitudinal USI, Doppler velocity, and arteriography data were obtained sequentially and independently for 713 carotid bifurcations. The internal carotid artery (ICA) residual lumen, the local outer diameter at the stenotic site, and the diameter distal to the bulb were measured in a representative USI longitudinal section. The peak systolic velocity and the end diastolic velocity (EDV) were measured at the stenosis. Local stenosis as determined with USI was compared with the x-ray arteriographic clinical radiology interpretation (XRI). As the primary method, radiologists compared the residual lumen with the distal ICA diameter, as recommended by the North American Symptomatic Carotid Endarterectomy Trial and the Asymptomatic Carotid Atherosclerosis Study. Analysis was by means of the USI positive predictive value (PPV) and negative predictive value (NPV) of the XRI findings, with the assumption that 80%, 70%, and 60% local stenosis with USI related to 70%, 60%, and 50% stenosis with XRI, respectively. RESULTS: All 56 ICA occlusions as determined with USI were confirmed with XRI. When the USI showed 80% to 99% stenosis, the PPV of the XRI showing 70% to 99% stenosis was 94% (116/123). Two ICAs that were shown to be severely diseased with USI appeared to be occluded with XRI. For <50% stenosis shown with USI, the prediction of <50% stenosis shown with XRI was 94% (253/269). For borderline stenosis in the 50% to 79% range with USI, the addition of velocity criteria to USI data improved both the PPV and the NPV. In the range of 70% to 79% stenosis with USI, the PPV improved from 82% (76/93) to 91% (53/58) for the subgroup with an EDV of more than 80 cm/s. For the range of 60% to 69% stenosis with USI, the PPV improved from 75% (71/95) to 95% (21/22) for the subgroup with an EDV of more than 80 cm/s. In the range of 50% to 59% stenosis with USI, the NPV improved from 69% (53/77) to 93% (14/15) for the subset with a peak systolic velocity of less than 100 cm/s. CONCLUSION: On the basis of the USI data alone, a prediction of arteriographic findings was possible at the 95% level for occlusion and severe stenosis and for ruling out hemodynamically significant stenosis. The addition of velocity data improved prediction in borderline degrees of stenosis. USI was effective for quantifying clinically significant degrees of stenosis.

Values and limitations of duplex ultrasonography as the sole imaging method of preoperative evaluation for popliteal and infrapopliteal bypasses.

The purpose of this study was to evaluate whether duplex ultrasound arterial mapping (DAM) can reliably replace standard arteriography (SA) in the preoperative assessment of candidates for popliteal and infrapopliteal bypasses. This is the report of a two-phase study undertaken at our institution from July 1997 to May 1998. Carefully performed DAM averted the need for preoperative SA (51 of 58 procedures). The results of this study can be used as an impetus to initiate larger, multicenter protocols to further evaluate this newer noninvasive approach for patients presenting with severe lower-limb ischemia.

Lower extremity arterial evaluation: are segmental arterial blood pressures worthwhile?

PURPOSE: Physiologic observations with blood flow waveform analysis and pressure measurements can document the severity of lower extremity arterial disease. Segmental blood pressures (SEGPs) taken at the thigh, calf, and ankle are commonly used, but their utility has seldom been studied. We quantified improvements in accuracy compared with arteriography when ankle pressures alone (ABI) or SEGP data were added to velocity waveforms obtained by Doppler ultrasound. METHODS: Continuous-wave Doppler velocity waveforms were recorded at common femoral (CFA), popliteal (POP), and dorsal pedal and posterior tibial (TIB) arterial levels. Systolic SEGP data were obtained with appropriately sized upper thigh, upper calf, and ankle cuffs. Waveforms, waveforms plus ABI, and waveforms plus SEGP data from 81 patients were randomly interpreted by 14 technologists or physicians from four institutions blinded to clinical and arteriographic data. Arteriograms were assigned negative or significant, severe (>75% diameter stenosis) values for four segments: iliofemoral (CFA), superficial femoral (SFA), popliteal (POP), and infrapopliteal (TIB) arteries. A total of 9072 segmental interpretations were analyzed. RESULTS: Compared with arteriography, the accuracy of waveform analysis was 83% for severe disease at and proximal to the CFA, 79% for SFA disease, 64% for POP disease, and 73% for TIB disease. Adding ABI improved the accuracy significantly (p < 0.01) to 88% (CFA), 86% (SFA), 70% (POP), and 85% (TIB). Accuracy was inferior when SEGP data replaced ABI: 86% (CFA), 85% (SFA), 70% (POP), and 80% (TIB). CONCLUSIONS: ABIs significantly improved Doppler waveform accuracy at all levels. Compared with ABI, the addition of segmental pressure to waveform data failed to improve accuracy. Pressure measurements above the ankle may lack cost effectiveness and clinical utility.

Biplane color flow duplex intravenous intravascular ultrasound for arterial visualization.

PURPOSE: To describe a feasibility study in a sheep model using an intravascular ultrasound (IVUS) instrument in an intravenous position to produce color flow, B-mode images of arterial segments along with Doppler blood flow velocities. METHODS: Four healthy adult male sheep were anesthetized for surgical exposure of the right external jugular vein. A 9.0F sheath was also introduced in the common femoral artery for arteriography and device insertion. A 7.5-MHz ultrasound probe with 1-cm graduation markers was passed into the jugular vein. B-mode and color flow pictures were captured at aortic branches in cross and longitudinal sections. Length measurements between aortic branches and Doppler spectral velocities were obtained. Guidewire, balloon, and stent maneuvers were monitored by the stationary intravenous IVUS probe. RESULTS: High-quality visualization of the entire abdominal aorta and its branches was achieved in all animals. With the probe stationary in the vena cava, a 1.5-cm linear segment of the aorta could be continuously observed in both B-mode and color flow ultrasound scans. Insertion and implantation of a Palmaz balloon-expandable stent was guided by intravenous IVUS alone. Selective catheterization of the right renal artery was followed visually by moving the intravenous IVUS probe sequentially. CONCLUSIONS: Intravenous IVUS appears feasible as a guidance and monitoring tool for endovascular interventions. While conventional IVUS provides only cross-sectional images in B-mode, intravenous IVUS captures color flow and Doppler velocity data as well. These added ultrasound modalities may offer potential advantages for guidance of endovascular procedures and endoleak detection.

Management of arterial occlusive disease following radiation therapy.

Clinically significant arterial occlusive disease developed in 26 patients at between 5 months and 44 years (mean(s.d.) 10.7(12.0) years) following radiation therapy. Therapeutic radiation was associated with lesions of the carotid artery (nine patients), subclavian-axillary arteries (seven) and the abdominal aorta and its branches (10). Clinical presentations included transient ischemic attack, stroke, vertebrobasilar insufficiency, carotid bruit, upper- or lower-extremity ischemia and renovascular hypertension. Surgery for cerebrovascular insufficiency included carotid endarterectomy with vein patch, interposition grafting or subclavian-to-carotid bypass. Carotid or subclavian-to-axillary bypass was performed for upper-extremity ischemia. A combination of endarterectomy and Dacron or saphenous vein grafts was used for infrarenal reconstruction. Tunnels were placed orthotopically. Musculocutaneous flaps assisted in healing selected wounds. Ureteral catheters were useful adjuncts in abdominal vascular reconstructions. There were no operative deaths, strokes or amputations. One patient had recurrent transient ischemic attacks following subclavian-to-carotid bypass. The mean(s.d.) postoperative follow-up was 48.1(39.6) months. Patients presenting with end-organ ischemia following radiation therapy can be managed successfully with aggressive surgical revascularization using a broad spectrum of reconstructive techniques.

Gender bias in use of venous ultrasonography for diagnosis of deep venous thrombosis.

PURPOSE: We observed that ultrasound examinations for deep venous thrombosis (DVT) were more frequently requested for women than for men in our vascular laboratory serving a general outpatient population and referral 774-bed hospital. Because existing literature presents conflicting information about sex differences in occurrence of DVT, we investigated correlation in our population with positive ultrasound study results and risk factors for DVT. METHODS: In 13 months, 2055 ultrasound examinations for DVT were requested. Of these, 300 patients (15%) were categorized in four subgroups: 75 ultrasonography-negative men, 75 ultrasonography-negative women, 75 ultrasonography (DVT)-positive men, and 75 ultrasonography (DVT)-positive women for risk factor analysis. RESULTS: Women comprised 64% (1311 of 2055) and men 36% (744 of 2055) of ultrasound examinations requested, but men had significantly higher incidence of DVT-positive ultrasonography results (101 of 744 [14%]) compared with women (118 of 1311 [9%]) (p = 0.002 by chi-square testing). There were no significant sex differences in conventional DVT risk factors and no difference in aggregate number of risk factors. The anatomic distribution of DVT was the same in men as in women. Among those having negative ultrasonography results, significantly more outpatient examinations were performed in women (p = 0.018 by t testing). CONCLUSIONS: Gender bias exists in use of ultrasonography for diagnosis of DVT. The greater incidence of women undergoing venous ultrasonography is not explained by higher prevalence of DVT risk factors or of higher occurrence of positive ultrasound examination results. Further investigation is needed to determine whether these differences indicate underuse of ultrasonography in men or overuse in women.

Preoperative assessment of alternative veins.

Duplex ultrasonography, with or without color flow, has replaced phlebography as the technique of choice to select veins for autogenous bypass grafts. Although anatomic location and length are well-defined by ultrasound, evaluation of the venous wall itself is still imperfect. In situ diameters are less than those of arterialized veins. Ultrasonic search is most valuable in the examination of patients with good veins obscured by a layer of fat. Preoperative knowledge of variant anatomy and location of major veins and their branches facilitates bypass surgery. The preoperative vein mapping should be available in the operating room to guide the placement of incisions for unroofing and exploration directly over veins and vein segments that have a high likelihood of being usable. The finding of a useful vein when none is apparent on physical examination may enable the construction of an autogenous bypass in lieu of a less desirable prosthetic graft or leg amputation.

Percutaneous transluminal angioplasty of the lower extremities by the vascular surgeon.

As vascular surgeons, we performed 376 percutaneous transluminal angioplasties as follows: aorta and iliac arteries (148), infrainguinal arteries (191), and bypass grafts (21). Sixteen procedures were attempted but not completed. Neodymium-yttrium-aluminum-garnet laser thermoprobe was successfully used prior to balloon dilatations in 49 procedures. In contrast to our experience with operative intervention, percutaneous transluminal angioplasty was performed more frequently for claudication (75%), nondiabetics (72%), and women (45%). Median age was 71 years. Percutaneous transluminal angioplasty either preceded or followed proximal or distal open reconstruction in 58 extremities. Primary patency rates for iliac percutaneous transluminal angioplasties were: 94% at one month, 93% at six months, and 88% at one year. For infrainguinal percutaneous transluminal angioplasties they were 95%, 82%, and 70% at 1, 6, and 12 months, respectively. Repeat percutaneous transluminal angioplasty increased the one-year patency rates to 92% and 86% for iliac and infrainguinal percutaneous transluminal angioplasties, respectively. Preliminary data indicate that the six-month secondary patency rates were 82% for laser-assisted percutaneous transluminal angioplasty and 65% for percutaneous transluminal angioplasty of distal bypass grafts. The implementation of balloon angioplasty was facilitated by our 21 years of experience with arteriography. Percutaneous transluminal angioplasty has become a valuable adjunct to the practice of vascular surgery by expanding the therapeutic options for managing peripheral vascular occlusive disease.

Successful percutaneous angioplasty after failed femorodistal bypass.

Although balloon angioplasty for the management of failing bypass grafts has been well documented, little mention has been made of its use in treating the occlusive lesion within the native artery after a failed bypass graft. We report our experience with five patients in whom successful balloon angioplasty was carried out subsequent to failure of a femoral popliteal bypass graft. Increasingly aggressive percutaneous therapy of arterial occlusive disease may now be expanded to include a unique group of patients with chronically failed bypass grafts and occlusive disease within the native artery conducive to percutaneous transluminal angioplasty. This group of patients would previously have been relegated to repeat bypass grafts with its inherently inferior patency and recognized added technical demands. Percutaneous balloon angioplasty appears to be a plausible alternative in selected cases for repeat lower extremity revascularization.

Preoperative duplex scanning prior to infrainguinal revascularization.

Arterial occlusive disease has been successfully evaluated with ultrasonography prior to infrainguinal revascularization; this technique contributes to design of operation and, in the case of a bypass, to the selection of a venous conduit. Techniques of black-and-white and color sonoangiography of the peripheral arteries and veins comprise imaging and blood velocimetry. Velocity and flow measurements and other data in the literature that compare ultrasound and radiologic techniques indicate that sonoangiography is already the "practical standard" for vein selection and will have a growing role in preparation for infrainguinal revascularization.

Lateral plantar artery bypass grafting: defining the limits of foot revascularization.

We placed 20 bypass grafts to the lateral plantar artery in 18 extremities to salvage feet with wet (12) or dry (six) gangrene; 15 grafts were implanted in men (75%), and five were implanted in women (25%). The median age was 65 years. All except two patients had diabetes; eight were treated with insulin. One patient had Buerger's disease, and another had vasculitis with chronic lymphocytic leukemia. History of smoking (65%), hypertension (53%), heart disease (71%), and osteomyelitis in the foot (35%), were noted. Cultures were positive in 15 gangrenous feet, 11 with gram-negative bacilli. Four long femoroplantar bypasses were placed. Ten short grafts were placed from the popliteal artery, and six jump grafts were placed distal to a femoropopliteal or tibial bypass. Hospital stay ranged from 8 to 38 days (median 16 days), and there were two in-hospital deaths. Transmetatarsal or button toe amputations were performed in nine feet. There were two below-knee amputations, one with a patent graft, for a foot salvage rate of 89% at 2 months. In four instances the gangrenous ulcers took longer than 6 months to heal; all other wounds healed within 6 months. The primary and secondary patency rates were 85% at 1 month, and 73% at 3 months and thereafter. Four of five graft failures occurred in the two legs with repeat bypass graftings. All patients with successful revascularization are able to walk, and seven returned to work full time.

Changes in peripheral hemodynamics after percutaneous transluminal angioplasty.

We measured ankle/arm pressure indexes and blood flow rates before and after performing percutaneous transluminal angioplasty in 36 extremities. Flow rates through the leg were determined with a magnetic resonance blood flow scanner. All patients had claudication; one had gangrene, another had an ulcer, and two complained of rest pain. The median age was 65 years, and 72% were men. There were 25 dilations of the iliac artery, 12 of the superficial femoral artery, and eight of the popliteal arteries; nine patients had two arterial segments dilated. Nineteen legs had ankle/arm pressure indexes before percutaneous transluminal angioplasty of less than 0.80 (range 0.51 to 0.75); their flow rates averaged 40 +/- 20 (SD) ml/min. After percutaneous transluminal angioplasty flow and pressure increased significantly in 14 of these 19 legs, and three had no hemodynamic improvement; in one leg only pressure and in another only flow increased significantly. The remaining 17 extremities had ankle/arm pressure indexes before percutaneous transluminal angioplasty ranging from 0.81 to 1.09; their flow rates averaged 53 +/- 27 (SD) ml/min. Abnormal flow rates were detected in 15 of these 17 extremities. With near-normal ankle/arm pressure indexes no significant increase in pressure was anticipated. Flow rates augmented to 75 +/- 28 (SD) ml/min after percutaneous transluminal angioplasty; a significant increase in flow was noted in 12 legs (71%). For patients with ankle/arm indexes before percutaneous transluminal angioplasty of less than 0.80, either pressure or flow measurements should corroborate the benefits of the operation, whereas if the ankle arm index is greater than 0.80, flow measurements are most likely to substantiate changes in peripheral hemodynamics.

Bypass grafts to the ankle and foot.

Two hundred forty-three bypasses to paramalleolar arteries were performed in 224 extremities of 208 patients since 1971; 166 were implanted in men (68%) and 77 in women (32%). The median age was 73 years. Gangrene (61%), nonhealing ulcer (15%), rest pain (22%), and trauma (2%) were the indications for bypass. Usual risk factors were noted: diabetes (65%), smoking (51%), heart disease (46%), and hypertension (45%). The extent of occlusive disease dictated three graft configurations: long grafts originating in arteries proximal to the adductor tendon (n = 111), short grafts originating at or below the popliteal artery (n = 88), and jump grafts originating near the distal end of a previous femorodistal bypass (n = 44). The association between diabetes (incidence 80%) and gangrene (75%) in patients with short grafts was statistically significant (p less than 0.01). The 2-year secondary patency rate of long in situ grafts was 92% compared with 72% for other autogenous vein long grafts. The limb salvage rate for all autogenous vein long grafts was 90% at 3 years. The secondary patency rate at 3 years for short grafts was 81% and the limb salvage rate was 80%. There were four amputations with patent grafts. Primary and secondary patency rates of jump grafts were similar (53%), whereas the limb salvage rate was 89% at 2 years. Patency and limb salvage rates of rarely employed nonautogenous conduits were less than 35% at 1 year (long grafts). Bypass grafts to the ankle and foot are effective and durable and should be performed with autogenous vein.