Compromised cerebral blood flow reactivity is a predictor of stroke in patients with symptomatic carotid artery occlusive disease.

PURPOSE: The purpose of this study was to determine whether the hemodynamic consequences of extracranial carotid disease correlate with the risk of subsequent cerebral infarction. METHODS: In 95 patients with symptoms who had greater than or equal to 70% stenosis (31 patients) or who had occlusion (64 patients) of the ipsilateral carotid artery, cerebral blood flow was measured by the stable xenon/computed tomography technique both at baseline and after vasodilatory challenge with intravenous acetazolamide. Patients were stratified into group 1, 43 patients with no more than a 5% decrease in flow in any vascular territory, and group 2, 52 patients with greater than a 5% decrease in one or more vascular territories after an acetazolamide challenge. RESULTS: In group 2, 15 (28.9%) of 52 patients had a new stroke, but only one (2.3%) of 43 patients in group 1 did (p = 0.0005). Of patients with total carotid occlusion 10 (26%) of 38 in group 2 and none (0%) of 26 in group 1 had a new stroke (p = 0.003). Of patients with greater than or equal to 70% stenosis, five (36%) of 14 in group 2 and only one (6%) of 17 in group 1 had a stroke (p = 0.067). CONCLUSION: The loss of cerebral reactivity in patients with symptoms who had greater than or equal to 70% carotid stenosis or occlusion is an important predictor of impending cerebral infarction.

Analysis of lower extremity blood flow in the patient with peripheral vascular insufficiency: a guide for plastic surgeons.

Accurate assessment of lower extremity blood flow is critical in selecting appropriate therapy for patients with peripheral vascular disease and nonhealing wounds. Although physical examination provides an idea about the extent and significance of the disease, further evaluation, including both noninvasive and invasive studies, is routinely obtained. Appropriate studies will provide valuable information about the location and severity of disease, the need for revascularization before definitive wound coverage, and the likelihood of wound healing. A brief overview of vascular laboratory tests, highlighting the values and limitations of each, is presented here.

Probability of rupture of an abdominal aortic aneurysm after an unrelated operative procedure: a prospective study.

It has been assumed by some authors that patients with abdominal aortic aneurysms may be at increased risk of rupture after unrelated operations. From July 1986 to December 1989, 33 patients (29 men, 4 women) with a known abdominal aortic aneurysm underwent 45 operations. Twenty-eight patients had an infrarenal abdominal aortic aneurysm, and five patients had a thoracoabdominal aneurysm. The abdominal aortic aneurysm ranged in transverse diameter from 3.0 to 8.5 cm (average 5.6 cm). Twenty-seven patients underwent a single operation, and six patients had two or more (range of 1 to 6). Operations performed were abdominal (13); cardiothoracic (9); head/neck (2); other vascular (11); urologic (7); amputation (2); breast (1). General anesthesia was used in 29 procedures, spinal/epidural in 6, and regional/local in 10. One postoperative death occurred from cardiopulmonary failure. One patient died of a ruptured abdominal aortic aneurysm at 20 days after coronary artery bypass (1/33 patients [3%]; 1/45 operations [2%]). Fourteen patients had repair of their abdominal aortic aneurysm at a later date, an average of 18 weeks after operation. Four patients had abdominal aortic aneurysm considered too small to warrant resection (average 3.6 cm). Four patients were considered at excessive risk for elective repair. The five thoracoabdominal aneurysm were not repaired. Four patients are awaiting repair. During this same 40-month period, two other patients, not known to have an abdominal aortic aneurysm, died of a ruptured abdominal aortic aneurysm after another operative procedure, at 21 days and 77 days. All three ruptured abdominal aortic aneurysms were 5.0 cm or greater in transverse diameter.(ABSTRACT TRUNCATED AT 250 WORDS)

The management of aortoenteric and paraprosthetic fistulae.

Aortoenteric and aortic paraprosthetic fistulae are devastating complications. Most authors recommend total excision of the graft and revascularization of the lower extremities by extra-anatomic bypass. We reviewed the University of Pittsburgh experience with these fistulae in 15 patients between 1977 and 1987. There were 9 aortoenteric fistulae (AEF) and 6 paraprosthetic fistulae (PPF). Seven of the 9 AEF had no abscess surrounding the graft, but communication of the intestine with the aortic anastomosis. One patient died during operation. Six patients underwent a local repair or in situ replacement of the graft. All 6 of those patients survived operation without limb loss. Two of the 9 patients with AEF had evidence of graft infection and underwent total excision of the graft and extra-anatomic reconstruction. Both patients died, one of sepsis and one of aortic stump rupture. All 6 patients with PPF had clinical and operative evidence of overt graft infection and underwent total graft excision and extra-anatomic bypass. Two of these patients died secondary to sepsis. We conclude that AEF, without evidence of graft infection, were safely treated by local repair. Patients with PPF had infected grafts requiring graft removal with significant morbidity and mortality.