The predictive value of dipyridamole-thallium scintigraphy for cardiac risk assessment before major vascular surgery.

BACKGROUND: We prospectively examined the ability of dipyridamole thallium scintigraphy (DTS), as a preoperative screening test, to predict postoperative cardiac complications in patients undergoing peripheral arterial operations. METHODS: From November 1993 to November 1995, a DTS study was routinely performed preoperatively in 167 consecutive patients who underwent arterial operations in our hospital. The clinicians were blinded to DTS results. The type of operation was: carotid endarterectomy (n = 53), abdominal aortic aneurysm repair (n = 45), aortobifemoral bypass (n = 31), femoropopliteal bypass (n = 32) and others (n = 6). Clinical and scintigraphic data were collected and analyzed uni- and multivariantly in order to identify those variables that correlate with postoperative cardiac complications. RESULTS: Fifteen adverse cardiac events (three deaths, five myocardial infarctions, seven unstable anginas) occurred postoperatively among 167 patients (mortality: 1.8%, morbidity: 7.2%). Forty-four patients (26.3%) had a normal scintigraphic study, sixty (35.9%) had fixed defects and sixty-three (37.7%) had reversible defects. The most powerful predictive factors of cardiac complications in the multivariate analysis were the synchronous existence of three markers of coronary artery disease (angina pectoris, previous myocardial infarction, Q sign on ECG) and the presence of a reversible defect in the anterior segment of the left ventricle on DTS study. CONCLUSIONS: This study demonstrates that the careful and detailed clinical examination is of paramount importance in detecting "high risk" patients and that DTS should be performed as a supplementary test since it offers significant information and further classifies patients of intermediate risk to develop postoperative cardiac complications.

Combined vascular reconstruction and adjunctive tissue transfer in the treatment of infected arterial prostheses and tissue defects.

One of the most serious complications in vascular surgery is infection of the vascular arterial prosthesis (VAP) which might lead to loss of limb or even death. Very often infected prostheses are combined with infectious infiltration of the adjacent tissues or even necrosis and their loss. This paper deals with the experience in the management of 5 patients suffering from infection of vascular arterial prostheses in various locations, for by-passing abdominal aorta and distal arteries with loss or necrosis of the skin and tissues adjacent to the graft. Removal of the infected graft was performed in all of the cases, together with wide debridement of the infested area and placement of a new graft, coursing far from the infected area for revascularization of the affected limb. The cleaned infected area was covered at a first or second stage by applying plastic procedures utilizing musculocutaneous tissue transfer. The results were quite satisfactory. We conclude that the management of infected vascular arterial prostheses, when these are combined with loss of adjacent tissues, is a challenge for the Vascular Surgeon. Their removal, extended cleaning and covering of the area by means of plastic procedures with tissue transfer, proved to be effective in the management of this problem.

Carotid endarterectomy and patch angioplasty, utilizing a segment of autogenous endarterectomized superficial femoral artery. A case report.

A case of a male patient, who had undergone a left internal carotid endarterectomy and arterial patch angioplasty is presented. After endarterectomy, arteriotomy was completed with a patch taken from the initial segment of a completely occluded superficial femoral artery, which was properly endarterectomized. The technique of arterial patch endarterectomy preservation is described and special emphasis is given to the advantages of deep endarterectomy on the possible beneficial long-term patency, as well as the availability of this autogenous material, in cases where the SFA artery is completely occluded.