Perioperative humoral stress response to laparoscopic versus open aortobifemoral bypass surgery.

Minimally invasive surgery seems to reduce hormonal stress response to surgery, but has not previously been examined in major abdominal vascular surgery. Aortic cross-clamping time and operation time is known to be longer in the totally laparoscopic aortobifemoral bypass (LABF) as compared to open aortobifemoral bypass (OABF). The main objective of our study was to measure the hormonal stress response during surgery and aortic cross-clamping in patients undergoing a totally laparoscopic versus an open aortobifemoral bypass. This was a sub-study of a larger randomized controlled multicentre trial. Thirty consecutive patients with severe aortoiliac occlusive disease were randomized to either a laparoscopic (LABF) or an open (OABF) procedure. The surgical stress response was measured by perioperative monitoring of adrenocorticotropic hormone (ACTH), aldosterone, metanephrine and cortisol at eight different time-points. During surgery. there was an increase in all humoral stress markers in both groups. The analysis of covariance showed increased levels of cortisol and ACTH in open group at 24 h time-point as compared to the baseline and this difference was statistically significant between the two groups, which indicate an earlier return to baseline levels in the laparoscopic group. Results from the General Estimated Equations (GEE) model indicate that LABF generates a lower level of metanephrine and higher level of aldosterone as compared to OABF. In conclusion, although they have higher levels of ACTH, aldosterone and cortisol during surgery, the patients operated with a laparoscopic aortobifemoral bypass achieve earlier hormonal homeostasis after surgery compared to open aortobifemoral bypass.

Radiation exposure in patients treated with endovascular aneurysm repair: what is the risk of cancer, and can we justify treating younger patients?

Background Endovascular aneurysm repair (EVAR) is becoming the mainstay treatment of abdominal aortic aneurisms (AAA). The postoperative follow-up regime includes a lifelong series of CT angiograms (CTAs) at different intervals in addition to EVAR, which will confer significant cumulative radiation exposure over time. Purpose To examine the impact of age and follow-up regime over time on cumulative radiation exposure and attributable cancer risk after EVAR. Material and Methods We calculated a mean effective dose (ED) for the EVAR procedure, CTA, and plain abdominal X-rays (PAX). Cumulative ED was calculated for standard, complex, and simplified surveillance over 5, 10, and 15 years for different age groups. Results For EVAR, the mean ED was 34 mSv (range, 12-75 mSv) per procedure. For PAX, the ED was 1.1 mSv (range, 0.3-4.4 mSv), and for CTA it was 8.0 mSv (range, 2-20 mSv). For a 55-year-old man, an attributable cancer risk (ACR) in standard surveillance at 5 and 15 years of follow-up was 0.35% and 0.65%, respectively. The corresponding values were 0.22% and 0.37% for a 75-year-old man. When using a simplified follow-up, the ACRs for a 55-year-old at 5 and 15 years were 0.30% and 0.37%, respectively. These values were 0.18% and 0.21% for a 75-year-old man. A complex follow-up with half-yearly CTA over similar age and time span doubled the ACR. Conclusion Treating younger patients with EVAR poses a low ACR of 0.65% (15-year standard surveillance) compared to a lifetime cancer risk of 44%. A simplified surveillance should be used if treating younger patients, which will halve the ACR over 15 years.

The effects of intermittent negative pressure on the lower extremities' peripheral circulation and wound healing in four patients with lower limb ischemia and hard-to-heal leg ulcers: a case report.

Peripheral circulation is severely compromised in the advanced stages of peripheral arterial disease. Recently, it was shown that the application of -40 mmHg intermittent negative pressure (INP) to the lower leg and foot enhances macro- and microcirculation in healthy volunteers. In this case report, we describe the effects of INP treatment on four patients with lower limb ischemia and hard-to-heal leg and foot ulcers. We hypothesized that INP therapy may have beneficial hemodynamic and clinical effects in the patients. Four patients (age range: 61-79 years) with hard-to-heal leg and foot ulcers (6-24 months) and ankle-brachial pressure indices of ≤0.60 on the affected side were included. They were treated with an 8-week intervention period of -40 mmHg INP (10 sec negative pressure and 7 sec atmospheric pressure) on the lower limbs. A custom-made vacuum chamber was used to apply INP to the affected lower leg and foot for 2 h per day. After 8 weeks of INP therapy, one ulcer healed completely, while the other three ulcers were almost completely healed. These cases suggest that INP may facilitate wound healing. The theoretical foundation is that INP assists wound healing by improving blood flow to the small blood vessels in the affected limb, increasing the flow of oxygen and nutrients to the cells.

Comparison of the acute-phase response after laparoscopic versus open aortobifemoral bypass surgery: a substudy of a randomized controlled trial.

PURPOSE: Minimally invasive surgical techniques have been shown to reduce the inflammatory response related to a surgical procedure. The main objective of our study was to measure the inflammatory response in patients undergoing a totally laparoscopic versus open aortobifemoral bypass surgery. This is the first randomized trial on subjects in this population. PATIENTS AND METHODS: This is a substudy of a larger randomized controlled multicenter trial (Norwegian Laparoscopic Aortic Surgery Trial). Thirty consecutive patients with severe aortoiliac occlusive disease eligible for aortobifemoral bypass surgery were randomized to either a totally laparoscopic (n=14) or an open surgical procedure (n=16). The inflammatory response was measured by perioperative monitoring of serum interleukin-6 (IL-6), IL-8, and C-reactive protein (CRP) at six different time points. RESULTS: The inflammatory reaction caused by the laparoscopic procedure was reduced compared with open surgery. IL-6 was significantly lower after the laparoscopic procedure, measured by comparing area under the curve (AUC), and after adjusting for the confounding effect of coronary heart disease (P=0.010). The differences in serum levels of IL-8 and CRP did not reach statistical significance. CONCLUSION: In this substudy of a randomized controlled trial comparing laparoscopic and open aortobifemoral bypass surgeries, we found a decreased perioperative inflammatory response after the laparoscopic procedure measured by comparing AUC for serum IL-6.

Application of intermittent negative pressure on the lower extremity and its effect on macro- and microcirculation in the foot of healthy volunteers.

Intermittent negative pressure (INP) applied to the lower leg and foot may increase peripheral circulation. However, it is not clear how different patterns of INP affect macro- and microcirculation in the foot. The aim of this study was therefore to determine the effect of different patterns of negative pressure on foot perfusion in healthy volunteers. We hypothesized that short periods with INP would elicit an increase in foot perfusion compared to no negative pressure. In 23 healthy volunteers, we continuously recorded blood flow velocity in a distal foot artery, skin blood flow, heart rate, and blood pressure during application of different patterns of negative pressure (-40 mmHg) to the lower leg. Each participant had their right leg inside an airtight chamber connected to an INP generator. After a baseline period at atmospheric pressure, we applied four different 120 sec sequences with either constant negative pressure or different INP patterns, in a randomized order. The results showed corresponding fluctuations in blood flow velocity and skin blood flow throughout the INP sequences. Blood flow velocity reached a maximum at 4 sec after the onset of negative pressure (average 44% increase above baseline, P < 0.001). Skin blood flow and skin temperature increased during all INP sequences (P < 0.001). During constant negative pressure, average blood flow velocity, skin blood flow, and skin temperature decreased (P < 0.001). In conclusion, we observed increased foot perfusion in healthy volunteers after the application of INP on the lower limb.

Polymorphisms in the interleukin-10 gene and chronic periodontitis in patients with atherosclerotic and aortic aneurysmal vascular diseases.

BACKGROUND: Chronic periodontitis (CP), atherosclerotic and aortic aneurysmal vascular diseases (VD) are chronic inflammatory conditions with multifactorial etiologies, including involvement of predisposing genetic factors. In a previous study, polymorphisms in the gene for the anti-inflammatory interleukin-1 receptor antagonist were associated with CP in patients with VD. OBJECTIVE: This study investigates whether polymorphisms in the gene for the anti-inflammatory interleukin-10 (IL10) could be related to CP in the same manner. METHODS: Seventy-two patients with VD of whom 35 had CP were genotyped for single nucleotide polymorphisms (SNPs) in the IL10 -592 (rs1800872), -819 (rs1800871), and -1,082 (rs1800896) gene by Taqman rtPCR method and by DNA sequencing. RESULTS: The C alleles and C/C genotypes of IL10 -592 and IL10 -819 frequencies were significantly higher, while the frequencies of the IL10 -592 (C/A) and IL10 -819 (C/T) heterozygote genotypes were significantly lower in the VD group with CP compared to those without CP. The IL10 haplotype ATA frequency (-1,082, -819, -592) showed a trend to a significant difference between the two groups indicating protection against CP. CONCLUSIONS: Taken together, our findings suggest an independent association of genetic polymorphisms in the IL-10 gene locus with CP in patients with VD. Development of CP and the implications on vascular disease emphasize the importance of early detection and adequate treatment of periodontitis among these patients.

Successful tissue engineering of competent allogeneic venous valves.

OBJECTIVE: The purpose of this study was to evaluate whether tissue-engineered human allogeneic vein valves have a normal closure time (competency) and tolerate reflux pressure in vitro. METHODS: Fifteen human allogeneic femoral vein segments containing valves were harvested from cadavers. Valve closure time and resistance to reflux pressure (100 mm Hg) were assessed in an in vitro model to verify competency of the vein valves. The segments were tissue engineered using the technology of decellularization (DC) and recellularization (RC). The decellularized and recellularized vein segments were characterized biochemically, immunohistochemically, and biomechanically. RESULTS: Four of 15 veins with valves were found to be incompetent immediately after harvest. In total, 2 of 4 segments with incompetent valves and 10 of 11 segments with competent valves were further decellularized using detergents and DNAse. DC resulted in significant decrease in host DNA compared with controls. DC scaffolds, however, retained major extracellular matrix proteins and mechanical integrity. RC resulted in successful repopulation of the lumen and valves of the scaffold with endothelial and smooth muscle cells. Valve mechanical parameters were similar to the native tissue even after DC. Eight of 10 veins with competent valves remained competent even after DC and RC, whereas the two incompetent valves remained incompetent even after DC and RC. The valve closure time to reflux pressure of the tissue-engineered veins was <0.5 second. CONCLUSIONS: Tissue-engineered veins with valves provide a valid template for future preclinical studies and eventual clinical applications. This technique may enable replacement of diseased incompetent or damaged deep veins to treat axial reflux and thus reduce ambulatory venous hypertension.

Effects of 12 Weeks of Supervised Exercise After Endovascular Treatment: A Randomized Clinical Trial.

BACKGROUND AND PURPOSE: This study aimed to assess the effects of supervised exercise training (SET) after percutaneous transluminal angioplasty (PTA) compared with PTA alone on physical function, limb hemodynamics and health-related quality of life in patients with intermittent claudication. METHODS: Fifty patients who all underwent PTA for intermittent claudication were included in the study. Both groups received usual post-operative care. In addition, the intervention group performed two sessions of hospital-based SET and one home-based exercise session per week for 12 weeks after PTA. The control group did not receive any additional follow-up regarding exercise. The primary outcome was the result of a standardized 6-minute walk test. Secondary outcomes were the treadmill maximum walking distance, treadmill pain-free walking distance, ankle-brachial index, pulse volume recording on the leg and ultrasound scanning. Health-related quality of life was measured using the Short Form 36 and the Claudication Scale. RESULTS: All measures, except for the Short Form 36 domain of mental health, showed statistically significant positive changes from baseline to 3 months for both groups (p < 0.05). At 3 months, there was a trend towards better results for the intervention group compared with the control group. The median improvement from baseline to 3 months for the 6-minute walk test was 66 m for the intervention group and 45 m for the control group. For maximum walking distance, the median improvement was 251 m for the intervention group and 93 m for the control group. DISCUSSION: Supervised exercise training after endovascular treatment for patients with intermittent claudication led to greater positive changes after 3 months in the intervention group compared with the control group. The present study's trends of better results with SET after PTA add to the emerging existing evidence, which should encourage physiotherapy practice to offer SET for this patient group.

Bacteria and bacterial DNA in atherosclerotic plaque and aneurysmal wall biopsies from patients with and without periodontitis.

BACKGROUND: Several studies have reported an association between chronic periodontitis (CP) and cardiovascular diseases. Detection of periodontopathogens, including red complex bacteria (RCB), in vascular lesions has suggested these bacteria to be involved in the pathogenesis of atherosclerosis and abdominal aortic aneurysms. OBJECTIVE: In this study, we investigate bacteria and their DNA in vascular biopsies from patients with vascular diseases (VD; i.e. abdominal aortic aneurysms, atherosclerotic carotid, and common femoral arteries), with and without CP. METHODS: DNA was extracted from vascular biopsies selected from 40 VD patients: 30 with CP and 10 without CP. The V3-V5 region of the 16S rDNA (V3-V5) was polymerase chain reaction (PCR)-amplified, and the amplicons were cloned into Escherichia coli, sequenced, and classified (GenBank and the Human Oral Microbiome database). Species-specific primers were used for the detection of Porphyromonas gingivalis. In addition, 10 randomly selected vascular biopsies from the CP group were subjected to scanning electron microscopy (SEM) for visualization of bacteria. Checkerboard DNA-DNA hybridization was performed to assess the presence of RCB in 10 randomly selected subgingival plaque samples from CP patients. RESULTS: A higher load and mean diversity of bacteria were detected in vascular biopsies from VD patients with CP compared to those without CP. Enterobacteriaceae were frequently detected in vascular biopsies together with cultivable, commensal oral, and not-yet-cultured bacterial species. While 70% of the subgingival plaque samples from CP patients showed presence of RCB, only P. gingivalis was detected in one vascular biopsy. Bacterial cells were seen in all 10 vascular biopsies examined by SEM. CONCLUSIONS: A higher bacterial load and more diverse colonization were detected in VD lesions of CP patients as compared to patients without CP. This indicated that a multitude of bacterial species both from the gut and the oral cavity, rather than exclusively periodontopathogens, may be involved as additional risk factors in the pathogenesis of VD.

Twelve-months follow-up of supervised exercise after percutaneous transluminal angioplasty for intermittent claudication: a randomised clinical trial.

UNLABELLED: The aim of this study was to explore the effects during 12 months follow-up of 12 weeks of supervised exercise therapy (SET) after percutaneous transluminal angioplasty (PTA) compared to PTA alone on physical function, limb hemodynamics and health-related quality of life (HRQoL) in patients with intermittent claudication. Fifty patients were randomised to an intervention or a control group. Both groups received usual post-operative care and follow-up measurements at three, six and 12 months after PTA. The intervention group performed 12 weeks of SET after PTA. The control group did not receive any additional follow-up regarding exercise. During the 12 months' follow-up, the members of the intervention group had significantly better walking distance than the control group. The intervention group had a significantly higher HRQoL score in the physical component score of the SF-36, and the domains of physical function, bodily pain and vitality. For limb hemodynamics, there was a non-significant trend towards better results in the intervention group compared to the control group. CONCLUSION: SET after PTA yielded statistically significantly better results for walking distance and HRQoL in the intervention group than the control group during the 12 months of follow-up.

Changes in fibrinogen availability and utilization in an animal model of traumatic coagulopathy.

BACKGROUND: Impaired haemostasis following shock and tissue trauma is frequently detected in the trauma setting. These changes occur early, and are associated with increased mortality. The mechanism behind trauma-induced coagulopathy (TIC) is not clear. Several studies highlight the crucial role of fibrinogen in posttraumatic haemorrhage. This study explores the coagulation changes in a swine model of early TIC, with emphasis on fibrinogen levels and utilization of fibrinogen. METHODS: A total of 18 landrace pigs were anaesthetized and divided into four groups. The Trauma-Shock group (TS) were inflicted bilateral blast femoral fractures with concomitant soft tissue injury by a high-energy rifle shot to both hind legs, followed by controlled exsanguination. The Shock group (S) was exposed to shock by exsanguination, whereas a third group was exposed to trauma only (T). A fourth group (C) served as control. Physiological data, haematological measurements, blood gas analyses and conventional coagulation assays were recorded at baseline and repeatedly over 60 minutes. Thrombelastometry were performed by means of the tissue factor activated ExTEM assay and the platelet inhibiting FibTEM assay. Data were statistically analysed by repeated measurements analyses method. RESULTS: A significant reduction of fibrinogen concentration was observed in both the TS and S groups. INR increased significantly in the S group and differed significantly from the TS group. Maximum clot firmness (MCF) of the ExTEM assay was significantly reduced over time in both TS and S groups. In the FibTEM assay a significant shortening of the clotting time and an increase in MCF was observed in the TS group compared to the S group. CONCLUSION: Despite a reduction in clotting capability measured by ExTEM MCF and a reduced fibrinogen concentration, extensive tissue trauma may induce an increased fibrin based clotting activity that attenuates the hypocoagulable tendency in exsanguinated animals.

Review of postoperative CT and ultrasound for endovascular aneurysm repair using Talent stent graft: can we simplify the surveillance protocol and reduce the number of CT scans?

BACKGROUND: Simplifying a postoperative surveillance protocol for endovascular aneurysm repair (EVAR) requires quality control comparing computerized tomography (CT) and ultrasound (US) results of abdominal aortic aneurysm (AAA) diameter measurements and endoleaks. PURPOSE: To test if US is comparable to CT, then assess a simplified follow-up with our conventional surveillance to assess patient safety. MATERIAL AND METHODS: During 2001-2006, data on 56 patients treated with Talent stent graft were prospectively registered. Median follow-up was 41.5 months (range, 2-94 months), with CT, US, and plain film abdomen X-rays (PFA) at 1, 6, and 12 months, then yearly. Bland-Altman plot was used to assess the agreement between CT and US measuring the AAA diameters and mixed model by the time effect to assess the difference in diameter over time. Sensitivity and specificity for detection of endoleaks by US, with CT as 'gold standard' were calculated. A simplified surveillance protocol with US/PFA at 6 and 8 weeks, CT/US/PFA at 1 year, and yearly US/PFA thereafter, was evaluated. CT was carried out when poor visibility, endoleak detected, AAA diameter increase (≥5 mm) on US or migration (≥10 mm) on PFA. This regime was compared with our conventional follow-up protocol. RESULTS: Diameter measurements on US appear comparable to CT with 91% specificity and 85% sensitivity for endoleaks detected by US. Using the simplified surveillance protocol no endoleaks, migrations, or endotension requiring treatment were overlooked. The simplified protocol generated 53 selective CT scans, avoiding approximately 144 CT scans. If further simplified by omitting the 1-year CT scan, one type II endoleak would be missed with a 1-year delay, eliminating a further 45 CT scans. CONCLUSION: US appears comparable to CT in the follow-up of Talent stent grafts in our institution. The proposed simplified surveillance protocol seems safe and can lead to a significant reduction in the number of CT scans.

Thrombin generation and platelet activation related to subintimal percutaneous transluminal angioplasty.

OBJECTIVE: The purpose of this study was to measure the in vivo platelet activation and thrombin generation in arterial blood after passing a subintimal conduit. METHODS: Subintimal percutaneous transluminal angioplasty (SPTA) is a technique where a subintimal channel is created, allowing recanalization of long peripheral arterial occlusion. From 10 patients with intermittent claudication, undergoing successful SPTA for femoropopliteal occlusive disease, we collected antecubital venous blood samples immediately before treatment, preprocedural arterial blood samples taken at the entry level proximal to the vessel occlusion, and subsequently at the reentry level after successful recanalization. Venous follow-up blood samples were taken after 24 hours. Plasma concentrations of ß-thromboglobulin (ß-TG), RANTES, and Prothrombin fragment (F1 + 2), were determined by immunoassay. Fibrinogen binding to platelets, leukocyte-platelet adhesion, and P-selectin were determined by flow cytometry. RESULTS: We found a statistically significant transluminal increase in the plasma concentrations of RANTES, ß-TG and F1 + 2 (p = 0.002, 0.001 and 0.001 respectively), which all normalized within 24 hours. Platelet-leukocyte aggregates significantly decreased after 24 hours compared with preprocedural and preentry levels (3.26% versus 5.26 %, p = 0.017). P-selectin expression on circulating platelets was statistically significantly increased in the blood sample taken at the re-entry level compared with the pre-procedural and pre-entry level (p = 0.007). After 24 hours there was no statistically significant difference to pre-procedural levels. There was no significant change in platelet fibrinogen binding at any levels. CONCLUSION: When passing a subintimal conduit, in vivo sampled blood demonstrated an extremely rapid and substantial uniform platelet activation and thrombin generation.

Pro-inflammatory interleukins in patients operated on for proximal femur fracture.

OBJECTIVES: The aims of this study were to measure plasma IL 6 and IL 8 in patients with proximal femoral fracture (PFF) during the early phases of trauma and operation and to find out if there was any correlation between these ILs and the post-operative lower limb oedema. MATERIAL AND METHODS: Thirty patients with a median age of 81 years were grouped into pertrochanteric fracture (PTF) (n = 16) and femoral cervical fracture (FCF) (n = 14). Plasma interleukin levels were determined on blood samples obtained from the common femoral vein, immediately after hospital admission, 1 h before operation, and post-operatively at 1, 6, 12, 24, 48 h and on the 7th day. Thigh oedema was calculated by the frustum method. RESULTS: In the patients with PTF, maximum mean plasma IL-6 and IL-8 values were found, respectively at 24 h (45.12 pg/mL) and 6 hours (21.7 pg/mL) postoperatively. Whereas, in the patients with FCF, it was respectively, at 12 h (33.1 pg/mL) and 6 h (17.0 pg/mL), for IL-6 and IL-8 post operatively. The patients with PTF and FCF had respectively, 34.1% and 27.4% more thigh oedema in the operated limb on the 7th post-operative day as compared to the preoperative oedema volume (p<0.001). No significant correlation could be found between the plasma IL-6 and IL-8 levels and oedema in the operated limb. CONCLUSION: Increased levels of IL 6 and IL 8 suggest ongoing inflammation.

[Surgical treatment of chronic venous insufficiency]. / Kirurgi ved kronisk venøs insuffisiens.

BACKGROUND: Patients with chronic venous insufficiency (CVI) may develop serious symptoms such as pain, oedema, venous claudication and leg ulcers. Conventional therapy includes compression therapy, elevation of the extremities, and in some cases surgical elimination of superficial varicose veins. This article presents and discusses surgical treatment (reconstructive deep venous surgery and transplantation) and endovascular therapy (percutaneous recanalization of post-thrombotic deep venous occlusions). MATERIAL AND METHODS: The article is based on literature identified through non-systematic searches in the PubMed and Cochrane databases. RESULTS: After reconstructive deep venous surgery, ulcer healing is reported in 60-78 % of cases and clinical improvement in 90 %. After such surgery, the median ulcer-free period seems to be longer in primary (congenital, familial), 54 months, than in secondary (after deep vein thrombosis) chronic venous insufficiency (18 months). Recanalization of deep venous occlusions is successful in 90 % of patients who have undergone endovascular treatment of venous claudication and leg ulcer. INTERPRETATION: Reconstructive deep venous surgery constitutes a real treatment choice for patients with chronic venous insufficiency for whom conventional measures have failed. The benefits are ulcer-free periods, clinical improvement, return to work and improved quality of life.

[Surgical treatment of atherosclerosis in the lower limbs]. / Kirurgisk behandling av aterosklerose i underekstremitetene.

BACKGROUND: Walking exercise, smoking cessation and best medical therapy are cornerstones in all treatment of atherosclerosis. For patients with intermittent claudication or critical limb ischemia, endovascular therapy (which has developed substantially during the last decade) has become the first line treatment (when feasible). The aim of this article is to provide an overview of options for surgical treatment of peripheral atherosclerosis in the lower limbs. MATERIAL AND METHODS: The article is based on literature identified through a non-systematic search in PubMed, vascular textbooks and the authors' own clinical experience. RESULTS: When endovascular therapy has failed or is not feasible, open surgical techniques are used, such as endarterectomy and bypass surgery to the popliteal or distal arteries. Hybrid procedures, with femoral endarterectomy and distal or proximal endovascular intervention, are often used. Increased use of endovascular treatment reduces the procedural time, length of hospital stay and the rate of complications. In patients with extreme disease progression, primary amputation may still be the treatment of choice. INTERPRETATION: Surgical treatment of peripheral artery disease requires competence both within radiological intervention and open surgical treatment modalities.

Edema in the lower limb of patients operated on for proximal femoral fractures.

BACKGROUND: Patients with proximal femoral fracture (PFF) often develop postoperative edema in the operated limb. This may lead to reduced mobilization, increasing the length of hospitalization. It is therefore relevant to gain information about the extent and pathogenesis of this edema formation. METHODS: Forty-one patients with PFF (30 women and 11 men) were studied pre- and postoperatively. Patients were grouped into pertrochanteric fractures and femoral cervical fractures, according to the AO/ASIF classification of PFF. Thigh and calf volumes were calculated in both fractured and contralateral limbs preoperatively and on postoperative days 3, 5, 7, and 30. RESULTS: All patients with PFF developed edema in the operated limb. The greatest volume increase occurred on postoperative day 7 (p < 0.0005). The magnitude of edema in the thigh and the leg of patients with pertrochanteric fractures as compared with the nonoperative side was approximately twice as great as in those with femoral cervical fractures (p < 0.0001). There was a statistically significant daily increase in the volume of the operative limb as compared with the nonoperative side. Age and sex were not correlated with the extent of edema formation. Functionally significant deep venous thrombosis and local infection could be excluded as causative factors. CONCLUSIONS: Postoperative edema in the thigh and leg of the operated limb was considerable. The magnitude of edema formation was related to the severity of primary trauma and the type of osteosynthesis. Therefore, the operation performed for PFF should be minimally traumatic.

Blood pressure response to isometric exercise in patients with peripheral atherosclerotic disease.

BACKGROUND: The purpose of this study was to compare the circulatory responses to isometric exercise in patients with peripheral atherosclerotic disease (PAD) with healthy controls. METHODS: Eleven patients with diagnosed PAD, a control group of eleven healthy young adults, and a control group of eleven healthy age-matched adults participated. Blood pressure, heart rate, stroke volume, cardiac output, blood velocity in the brachial artery, acral skin perfusion was continuously recorded and total peripheral resistance calculated before, during and after 2 min of 40% maximum voluntary contraction of the forearm. RESULTS: At rest we found a consistently higher level of mean arterial pressure (MAP) and systolic pressure (SP) in the elderly, both PAD patients and elderly controls, compared with the young controls. We found no significant difference in diastolic blood pressure. Two minutes isometric handgrip exercise induced a similar increase in MAP in all three groups (patients 32.6 (17.9) mm Hg [mean (SD)], young control group 25.3 (8.9) mm Hg, age-matched control group 36.1 (10.6) mm Hg). No significant differences were found in the other measured cardiovascular variables during isometric handgrip. Increased TPR is the main factor contributing to the increase in blood pressure in all three groups. CONCLUSION: Our study indicates that the pressor response continues to be well regulated with age, also when the cardiovascular system is altered by marked atherosclerosis. The consequence is that both PAD patients and elderly controls reach higher SP values during isometric exercise due to higher SP baseline values.