Nonoperative therapy for postcatheterization femoral artery pseudoaneurysms.

Since November 1992, 160 patients were referred to the Vascular Surgery Laboratory for duplex scanning to assess whether a femoral artery pseudoaneurysm was present. Of these patients, 33 per cent (n = 53) had femoral artery pseudoaneurysms with maximal diameters ranging from 1.5 to 8.1 cm. Most pseudoaneurysms (79%; 42 of 53) followed diagnostic or therapeutic cardiac catheterization procedures. Pseudoaneurysms were treated by external compression using an ultrasound probe in 33 of these 53 patients, and thrombosis of the aneurysm was successfully induced in 76 per cent (n = 25) of those in whom nonoperative external compression therapy was attempted. Of the eight patients in whom compression was unsuccessful, three had severe pain that required cessation of compression, and femoral nerve involvement by the pseudoaneurysm was noted at surgery in two of the three. One additional patient refused a second attempt at compression due to discomfort. Of the other four failures of compression, four (50% overall) received anticoagulants during or prior to compression. In 25 patients with successful pseudoaneurysm thrombosis after external compression, none had severe pain from compression, and 40 per cent (n = 10) were on anticoagulants until or during compression. Four of the 53 (7.5%) pseudoaneurysms diagnosed in the vascular laboratory subsequently thrombosed spontaneously, and two patients (3.8%) experienced pseudoaneurysm rupture. Thrombosis of postcatheterization pseudoaneurysms can be achieved by nonoperative compression therapy in most patients. Severe pain during external compression suggests possible femoral nerve involvement by the pseudoaneurysm and is an indication for surgical therapy.

Vena cava duplex imaging before caval interruption.

PURPOSE: Venacavograms are routinely obtained before vena cava filter placement to evaluate cava size, patency, and the presence of thrombus or venous anomalies. The objective of this study was to determine the ability of duplex ultrasonography to adequately evaluate the inferior vena cava (IVC) for size, patency, and the presence of thrombus before Greenfield filter (GF) insertion. METHODS: Duplex ultrasonographic scans were performed in 40 patients who had documented lower-extremity deep venous thrombosis diagnosed by duplex scan before GF placement. The infrarenal transverse and anteroposterior diameters of the IVC were measured, and the entire IVC was imaged for patency and the presence of thrombus or anomalies. Preoperative venacavograms were not obtained in any patients who had GFs placed in the operating room, but was performed during surgery during filter insertion. An additional 26 patients who had deep venous thrombosis and did not have caval interruption underwent IVC duplex to determine the patency and proximal extent of venous thrombosis. RESULTS: The indications for GF placement were contraindication to anticoagulation in 72.5% (29 patients); five filters were placed prophylactically; three for failure of anticoagulation; two after a complication of anticoagulation; and one before pulmonary embolectomy. The filters were placed in the operating room by surgeons in 82.5% of patients, with the remainder inserted in an angiography suite by an interventional radiologist. The ability of duplex to measure a transverse diameter of 26 mm or less had a sensitivity of 97.5%, positive predictive value of 100%, and overall accuracy of 97.5% using venacavography as the standard. Measurements of IVC diameter by duplex correlated with those based on venacavograms (r = 0.766; p < 0.001). Of the entire group of 66 IVC duplex examinations, one (1.5%) was incomplete because of technical limitations. IVC thrombus was noted by duplex in two patients who underwent GF insertion, which was confirmed with venacavography. No IVC anomalies were noted by duplex scans or venacavograms. CONCLUSION: Duplex ultrasonography is a useful and accurate method for assessment of the IVC before vena cava filter placement.

Assessment of noninvasive lower extremity arterial testing versus pulse exam.

Palpation of pedal pulses was compared to noninvasive testing in 100 patients referred to a vascular laboratory. Subjects were 65 +/- 13 (mean +/- s.d.) years old. The right dorsalis pedis (DP) artery served as the reference artery for comparison of Doppler studies with physical examination of the pulses. Absolute Doppler pressures in the right DP were 129 +/- 50 mm Hg. The right ankle:brachial index (ABI) was 0.86 +/- 0.32. There were significant differences in ABI in those with (0.68 +/- 0.28) vs without (0.95 +/- 0.31) claudication in either extremity (p < 0.001). Rest pain was also associated with lower ABI (P < 0.04). Diabetics, hypertensives, claudicants and those with ischemic rest pain were less likely to have palpable pulses (P < 0.035). With right DP pressure >/= 118 mm Hg, 63 per cent of subjects had a palpable DP pulse, whereas 68 per cent with ABI > 0.82 had a palpable right DP. Of those (n = 35) with a right DP pressure < 118 mm Hg, only 6 per cent (n = 2) had a palpable pulse, whereas 5 per cent (2/40) with ABI /= 188 mm Hg and ABI > 0.82. The range of ankle pressures with palpable right DP pulses was 64-220 mm Hg, whereas the range with nonpalpable DP was 42-300 mm Hg. Given the frequent disparity of pulse exam and ankle pressures, noninvasive Doppler testing may be necessary for many patients to accurately assess the vascular status of the leg.

Lyme disease in children: diagnosis, treatment, and prevention.

Lyme disease is a multisystem disorder that is caused by infection with Borrelia burgdorferi. In endemic areas, its occurrence is extremely common among children. The early diagnosis and treatment of Lyme disease may prevent the development of serious cardiac, rheumatological, and neurological sequelae. For this reason, a full understanding of the clinical manifestations, laboratory evaluation, and antibiotic therapy of Lyme disease is of vital importance.

The laboratory diagnosis of Lyme disease.

Growing awareness of Lyme disease, caused by the tickborne spirochete Borrelia burgdorferi has led to a marked increase in laboratory procedures to help in its diagnosis. Despite the frequent ordering of serologic tests specific for Lyme disease, there remains confusion in the accurate interpretation of these tests. Because of the important cutaneous manifestations of B burgdorferi infection, dermatologists should understand the role of the laboratory in Borrelia-related conditions. This article reviews laboratory techniques available for the diagnosis of Lyme disease. The role of histologic findings and culture, the sensitivity, specificity, and reproducibility of commonly used serologic tests, the effects of disease duration and treatment on serologic results, and the future of laboratory diagnosis are described.

Sweating in ectodermal dysplasia syndromes. A review.

Ectodermal dysplasia syndromes are currently classified based on constellations of clinical features, a major one of which is the presence or absence of normal sweating. The evaluation of sweating in these disorders has not been performed in a standardized manner, as is shown here in this literature review of a sampling of ectodermal dysplasia syndromes. Accurate evaluation of sweating is important not only in enabling more effective diagnosis and classification of patients with these syndromes, but also in aiding genetic counseling by potential detection of carrier states. A review of the variety of sweat tests currently in use is presented.

Body composition changes in marrow transplant recipients receiving total parenteral nutrition.

Nine patients with acute lymphocytic leukemia in remission, aged 12-35 years, undergoing allogeneic bone marrow transplantation (BMT) were studied for changes in body fluid balance and body composition. Body composition and fluids were assessed the first 4 weeks following BMT, using isotope dilution and anthropometry. Oral and parenteral nutrient intakes were recorded daily. Tracer dilution techniques were used to assess body fluid volumes and estimate body cell, lean body, and body fat masses. Body cell mass was lost (mean -1.62 kg, P less than 0.05) without significant changes in body fat or lean body masses. There was an expansion of the extracellular fluid compartment (mean +0.8 l, P less than 0.05) and a loss in the intracellular fluid compartment (mean -1.3 l, P less than 0.05) with little change in total body water volume. Changes in body weight correlated poorly with body cell mass or fluid volume changes. Change in arm muscle area correlated well with changes in body cell mass (r = 0.61, P less than 0.05) and lean body mass (r = 0.68, P less than 0.05), while that of arm fat area did not reflect its isotope dilution-derived counterpart. Instead, the change in arm fat area was related to shifts in fluid compartments. Prealbumin decreased significantly (mean -9.3 mg/dl, P less than 0.05), while albumin decreased slightly (mean -0.1 mg/dl), and both were related to changes in body cell mass. Nitrogen balance was negative throughout the study and the overall mean was related to the change in body cell mass (r = 0.60, P less than 0.05). Calorie and protein intakes were not associated with the changes in body composition, implying other causal factors.