Amputation-Free Survival after Crural Percutaneous Transluminal Angioplasty for Critical Limb Ischemia.

BACKGROUND AND AIM: To evaluate the amputation-free survival after below the knee percutaneous transluminal angioplasty in a consecutive group of patients with critical ischemia of the lower extremity. MATERIALS AND METHODS: A total of 70 consecutive patients with critical ischemia were treated with below the knee percutaneous transluminal angioplasty at the vascular center at Rigshospitalet with the purpose of limb salvage. All patients were deemed unfit for major surgery due to anatomical limitations or severe co-morbidity, and no prior attempts of revascularization were performed. Follow-up clinical examinations were performed within 6 weeks and after 1 year. All medical records were crosschecked with the national vascular registry ensuring a valid 1-year status in 97% of the patients. RESULTS: A total of 15 major amputations were performed during follow-up, with 11 amputations performed within the first year. Complications after percutaneous transluminal angioplasty were rare. Cumulative mortality after 1 and 2 years was 22% and 34%, respectively. Amputation-free survival at 1 and 2 years of follow-up was 68% and 58%, respectively. There were no association between known risk factors such as diabetes, ischemic ulcers, cardiac disease, history of smoking, major amputation, or overall amputation. CONCLUSION: Below the knee percutaneous transluminal angioplasty in patients with end-stage peripheral arterial disease and critical limb ischemia is a safe procedure in relieving critical ischemia, reducing the short-term rate of a major amputation as opposed to best medical treatment alone.

Femoral pseudoaneurysms in drug addicts.

OBJECTIVE: To evaluate the outcome of treatment of femoral pseudoaneurysms in drug addicts. METHODS: The records of eight patients undergoing vascular surgery for femoral pseudoaneurysms from substance abuse identified from a vascular database were reviewed. RESULTS: Were good in four out of five patients who had a primary vascular reconstruction. Two out of two patients who had a triple ligation of their aneurysms had claudication postoperatively. One patient presenting with thrombosis had a hip-exarticulation following an unsuccessful thrombectomi. No death occurred in this series. CONCLUSION: Revascularisation at the time of resection of the pseudoaneurysm offers better prospects for limb function.

[Local intra-arterial thrombolysis in acute ischemia of an extremity]. / Lokal intraarteriel trombolyse ved akut ekstremitetsiskaemi.

The effect of intra-arterial local thrombolysis or peripheral arterial occlusions seems to be well documented. As assessed by angiography, primary recanalisation is achieved in 65-90%. Using recombinant tissue plasminogen activator thrombolysis is achieved more frequently (90% vs 65-85%) and faster (4-8 hours vs 12-48 hours) than when using streptokinase or urokinase. The most frequently used dosages are streptokinase 5000 IU/h, and recombinant tissue plasminogen activator 0.5 mg/h. So far, results from randomized trials between thrombolytic therapy and surgery have not been published.

[Thrombolytic therapy in acute lower extremity ischemia]. / Trombolysebehandling ved akut underekstremitetsiskaemi.

During a period of four and a half years 37 lower extremities with acute ischaemia were treated with thrombolysis. Angiographically, 35 cases demonstrated no suitable arteries for distal reconstruction. In two cases vascular surgery was not performed because of cardiac incompensation. Two patients died within one month and limb salvage was 69%. During 22 months (3-48) of follow-up another six patients were amputated two to nine months later. The 18 salvaged lower extremities (49%) had an ankle-brachial pressure index of 0.63 (0.30-1.-09). Review of all angiograms revealed a demonstrable effect of thrombolytic therapy only in 13 (35%) cases. In conclusion, thrombolytic therapy should be considered in the case of acute lower extremity ischaemia unsuitable for reconstructive procedures. Even though the effect of thrombolytic therapy cannot be demonstrated on the angiogram, that should not necessarily deem the treatment to be a failure.

[Femoral pseudoaneurysms in drug addicts]. / Femoralt pseudoaneurisme hos narkomaner.

Four cases of femoral pseudoaneurysms from substance abuse are presented. One patient, a 32 year-old women needed amputation (by disarticulation of the hip) after failed revascularization. Another patient had symptoms of claudication after triple ligation and resection without bypass grafting. The last two had an uneventful recovery: one after saphenous vein bypass, the other after simple resection and repair with a vein patch.

Effect of epidural anaesthesia on dorsal pedis arterial diameter and blood flow.

In nine subjects the influence of low (LE: blockade at or below the umbilicus; Th. 10) and high epidural anaesthesia (HE: block above the umbilicus) on vascular tone was evaluated by high frequency ultrasound (20 mHz) determined luminal diameter and a Doppler (8 mHz) assessment of mean blood flow velocity (Vmean) in the dorsalis pedis artery. The LE was induced by 0.5% bupivacain through a catheter at L3-L4, and HE was established by further infusion. Resting blood pressure and heart rate were not affected by LE or HE. One subject developed selective thoracic anaesthesia, and another was blocked on the contralateral side only. In the seven adequately blocked subjects, the luminal diameter of the dorsalis pedis artery increased from 1.70 (1.25-1.93) to 1.90 (1.75-2.23) mm during LE (+12%) and further to 2.08 (1.83-2.96) mm during HE (22%; P < 0.05). The Vmean was similar during control (7[4-26] cm s-1) and LE (12[4-55] cm s-1), but increased during HE to 35(12-78 cm s-1 (+500%; P < 0.05). Thus, arterial blood flow was higher during LE (21[7-98] ml min-1; +263%) and HE (94[21-177] ml min-1; +1175%) than at rest (8[7-36] ml min-1; P < 0.05). This study quantified the importance of sympathetic nerve activity for vascular tone and in turn blood flow in an artery of a resting human limb, as the diameter and Vmean increased with progressive epidural anaesthesia.

[Bilateral iliac artery aneurysms in a Behçet-like disease]. / Bilaterale iliacaaneurismer ved Behçet-lignende sygdom.

A case of bilateral iliac artery aneurysms in a 24 year old patient with a Behçet-like disease is presented. Behçet's disease is characterized by multiple organ involvement. Primary manifestations are genital and oral mucosal ulcerations and eye and skin affections. Among secondary manifestations are non-specific arteritis causing thrombosis as well as aneurysmal disease of the medium-sized and large arteries. Behçet's disease should be considered in young patients with arterial aneurysms.

Intra-arterial papaverine and leg vascular resistance during in situ bypass surgery with high or low epidural anaesthesia.

In situ saphenous vein arterial bypass flow was studied in 16 patients with respect to level of epidural anaesthesia. Arterial pressure and electromagnetic flow were used to evaluate arterial tone by intra-arterial (i.a.) papaverine. Eight patients had a low epidural block (< or = Th. 10) and eight patients were operated during high epidural anaesthesia (> Th. 10). Flow increased and arterial pressure decreased after i.a. papaverine in all patients. When compared with patients operated during high epidural anaesthesia, flow increase and decrease in vascular resistance took place in patients operated during low epidural anaesthesia (P < 0.02). Increase in arterial flow after i.a. papaverine was not significantly different in patients operated in low epidural and general anaesthesia (n = 8). In eight patients with insulin-dependent diabetes mellitus who had low epidural anaesthesia, the increase in flow after i.a. papaverine was not significantly different to that noted during high epidural anaesthesia. The results indicate that the level of analgesia influences graft flow after i.a. papaverine, probably reflecting differences in the effect of epidural anaesthesia on sympathetic tone to the leg.

[Doppler ultrasonography in arteriosclerosis of the lower extremities]. / Doppler-ultralydundersøgelse af underekstremitetsarteriosklerose.

Arteriography, which requires resources and is not entirely without risk, has hitherto been a prerequisite for reconstructive surgery in cases of symptom-producing arteriosclerosis in the lower limbs. As an alternative, indirect Doppler ultrasonic examination has been employed but does not appear to be suitable in the clinical routine. On the basis of a review of the literature, it is suggested that, employing a combination of ultrasonic picture scanning and Doppler ultrasonic duplex scanning, it may be possible to diagnose significant solitary stenoses or short occlusions in the aorto-iliac segment and in the femoral artery but that this does not appear to be employable at present in cases of multiple lesions. Examination of the popliteal artery is still too unreliable and reasonably certain assessment of the crural arteries is not possible with the present technique. Duplex scanning can thus not replace arteriography as yet for examination of patients with ischaemia in the lower limbs.

[Postoperative duplex ultrasonic surveillance of infrainguinal arterial reconstructions]. / Ultralyd-duplex-overvågning af infraingvinale arterielle rekonstruktioner.

Postoperative bypass surveillance can identify graft-related stenoses in 25% of grafts during the first two years after surgery. Correction of the stenoses before they lead to graft occlusion improves the patency significantly. Clinical assessment including distal pressure measurements is of poor sensitivity. Surveillance is best performed with color duplex scanning. Ideally, grafts are examined first after one to two months, thereafter every three months and, after one year, at intervals of six months. Graft surveillance beyond two years is hardly justified, as is the case with prosthetic grafts. Symptom-producing and tight stenoses should be corrected. Percutaneous transluminal angioplasty is appropriate for short stenoses, whereas stenoses longer than 2 to 3 cm are best treated surgically.

Ischemic colitis complicating imipramine overdose and alcohol ingestion. Case report.

Patients on antidepressant medication are instructed to avoid alcohol because of possible additive effects on cognitive function. An unusual case of colonic gangrene following overdose of imipramine and alcohol is presented. The patient recovered.

The effect of arteriovenous fistulas on in situ saphenous vein bypasses.

Intraoperative identification and later development of arteriovenous fistulas were investigated prospectively in 70 in situ saphenous vein bypass procedures. Surveillance was performed by completion arteriography and intra- and postoperative continuous wave Doppler examination. The intraoperative Doppler examination identified 89% of those branches with sufficient flow to opacify the deep venous system on completion arteriogram. Half of the missed fistulas underwent spontaneous thrombosis, and in only one case did the arteriovenous fistula lead to hemodynamic symptoms demanding surgical closure of the fistula. Pursuing a policy of selectively ligating fistulas that only fill the deep venous system on completion arteriography led to an additional nine arteriovenous fistulas. Developed over an average follow-up of six months, four patients presented symptoms of edema and swelling and were relieved upon closure of the fistulas. The incidence of bypass thrombosis did not differ significantly among patients with remaining arteriovenous fistulas, patients who developed fistulas during follow-up, and patients who had no signs of arteriovenous fistulas. It seems justified to continue selective intraoperative ligation of arteriovenous fistulas based on continuous wave Doppler.

Bricker's ileal conduit urinary diversion with a simple non-refluxing uretero ileal anastomosis.

Fifty consecutive patients had ileal conduits constructed with a technically and quick simple antireflux ureteroileal anastomosis. Complications related to the ureteral implantation were studied retrospectively, and at follow-up (8 months-12 years later, median 3 years) conduit dysfunction and ureteral reflux were assessed in 18 patients out of the 25 patients who were still alive. Early complications and signs of late upper urinary tract deterioration were similar to those found after other operative techniques had been used. One patient had a postoperative urinary leak from the uretero ileal anastomosis. which was treated successfully by two weeks drainage. Hydronephrosis deteriorated in 18 (26%) of the renal units, remained unchanged in 39 (57%) and improved in 11 (16%). Increases in plasma creatinine concentrations up to 200 mumol/l were found in eight patients, and in one patient it increased from 300 to 420 mumol/l. Partial ureteral reflux was present in three (2 patients) of 33 ureters studied and minimal conduit dysfunction was found in 8 patients. In conclusion we find this method of urinary diversion to be quick, easy, and safe.

[False negative mammography]. / Falsk negativ mammografi.

During the period 1.1.1984-31.12.1986, primary surgical treatment of 423 women with palpaple, invasively progressing cancer of the breast was performed. All of these had been examined mammographically prior to operation. The uncorrected nosographical sensitivity of the mammographic investigation was 0.93, decreasing to 0.83 prior to the age of 50 years. It is emphasized that patients in whom there is a disproportion between the mammographic and palpatory findings must be referred for surgical assessment without delay.

[Non-palpable tumors of the breast demonstrated by mammography]. / Ikke-palpable mammatumorer påvist ved mammografi.

During the period 1.1.1985-28.2.1987, 114 mammographic markings with needles were undertaken on cancer-suspect, non-palpable tumours of the breast in 106 patients. In 27.2% of the cases, carcinomata were found and, in 16.7%, carcinoma in situ. Mammographic examination combined with needle marking is recommended as a diagnostic supplement to clinical examination.

Microvascular circulatory changes in the lower extremities after reconstructive vascular surgery for intermittent claudication.

We have studied the circulatory changes in the lower extremities after reconstructive vascular surgery in ten patients with intermittent claudication. The following examinations were carried out 3 days before, 3 days, and 28 days after the operation: measurement of ankle systolic blood pressure, calf plethysmography, resting calf muscle blood flow and resting subcutaneous foot blood flow. The vasoconstrictor response (veno-arteriolar reflex) was also assessed. On the night before the operation and on the 28th night after aorto-bifemoral bypass surgery, subcutaneous adipose tissue blood flow in the forefoot was measured during sleep. The ankle systolic blood pressure and the ankle index rose significantly. The former increased from 57 +/- 16.4 mmHg to 93 +/- 24.0 mmHg (mean +/- S.E.M.) and was still elevated on the 28th postoperative day. The total limb blood flow, the muscle blood flow and the blood flow in the subcutaneous tissue of the forefoot during daytime were unchanged. In contrast, the blood flow in the forefoot during sleep increased significantly from 3.5 +/- 1.63 ml x (min x 100 g)-1 to 5.2 +/- 2.14 ml x (min x 100 g)-1 (mean +/- S.E.M.) on the 28th night. The vasoconstrictor response was potentiated, and increased from 27% before the operation to 45% on the third postoperative day. This change was maintained 28 days postoperatively. In conclusion the increase in arterial blood pressure was only reflected in the vasoconstrictor response which had returned to normal by the third postoperative day and nocturnal blood flow in the subcutaneous adipose tissue which did likewise.

Popliteal aneurysm after plate osteosynthesis. A case report.

A false aneurysm of the popliteal artery caused acute ischemic symptoms 23 years after plate osteosynthesis of a distal femoral fracture. The protruding tip of a screw was found in the center of the aneurysmal sac.

Acute appendicitis and plasma concentration of serotonin.

The concentration of serotonin in platelet-poor plasma was measured with a radioenzymatic method in 31 patients prior to operation for suspected acute appendicitis. The serotonin determinations were made without knowledge of the peroperative or histologic findings. Appendicitis was found in 20 patients, nine of whom had elevated plasma serotonin level, giving 45% sensitivity for the test. Of the 11 patients with normal appendix, only one had increased plasma serotonin, giving 91% specificity. The predictive value of normal serotonin level was 48% and that of elevated serotonin level was 90%. No correlation was found between duration of appendicitis symptoms and plasma serotonin concentration. Other diseases did not influence the serotonin level.