Cholecystectomy.

We retrospectively reviewed 360 consecutive cholecystectomies done by the four surgeons in our private group practice. No patient had dehiscence of the wound or evisceration. One patient had a seroma, which was opened in the office, but the fluid contained no white blood cells or bacteria on smear, and the culture was negative. No deaths occurred during the hospitalization or within 30 days after the operation. Routine perioperative antibiotics were used, and most wounds were drained with closed suction drainage. Routine intraoperative cholangiography was also done. On the basis of the favorable morbidity and mortality in this large group of patients and a review of the literature, we recommend the routine use of antibiotics and cholecystectomy for most patients with gallstones.

A prospective evaluation of indirect methods for detecting carotid atherosclerosis.

The statistical efficacy of three indirect techniques for noninvasive diagnosis of carotid artery disease was assessed in a prospective, blind study of 103 persons. Oculoplethysmography-carotid phonoangiography, periorbital Doppler examination and supraorbital photoplethysmography were acceptably sensitive only to carotid artery occlusions and preocclusive carotid artery stenoses exceeding a 75 per cent diameter reduction. Less pronounced lesions could not be reliably detected by any of the techniques used either singly or in combination. Supraorbital photoplethysmography proved inferior to the other methods because of its poor specificity rate.

Toe blood pressure by photoplethysmography: an index of healing in forefoot amputation.

The relative merits of toe systolic blood pressure and ankle systolic pressure in predicting the result of forefoot amputation were evaluated in 30 limbs of 27 patients who underwent digit or transmetatarsal amputation. Twenty-four (89%) patients were diabetic. An infrared photoplethysmograph placed distal to a pneumatic digit occluding cuff allowed rapid, simple preoperative assessment of toe systolic pressures. Ankle pressures was measured by Doppler ultrasound. Twenty (67%) amputations healed primarily, whereas 10 ultimately required reamputation at the below-knee level. The mean ankle pressure of limbs with healing of forefoot amputation, 136 +/- 39 mm Hg (+/- SD), did not differ significantly from those that failed to heal, 121 +/- 72 mm Hg (P greater than 0.4). Failure of an amputation to heal occurred in association with ankle pressures ranging from 60 to over 300 mm Hg. The mean value of toe pressures associated with healing of forefoot amputation, 86 +/- 39 mm Hg, was significantly higher than those not healing, 25 +/- 18 mm Hg (P less than 0.001). Failure of a forefoot amputation to heal occurred in all eight limbs with toe pressures less than 45 mm Hg, and in two of eight (25%) limbs with toe pressure between 45 and 55 mm Hg. Primary healing occurred in all 14 limbs with toe pressures greater than 55 mm Hg. These data suggest that toe pressure measurement may be a useful hemodynamic correlate of the healing potential of a forefoot amputation.

Management of penetrating injuries of the internal carotid artery at the base of the skull utilizing extracranial-intracranial bypass.

Penetrating injuries of the internal carotid artery at the base of the skull often require permanent or transient occlusion of the injured vessel during repair. Extracranial-intracranial bypass (EC-IC) was employed in five patients to insure adequate cerebral perfusion during cervical exploration. Preoperative neurologic deficits were noted in three patients; two demonstrated complete reversal following EC-IC. This experience suggests that EC-IC can maintain adequate cerebral perfusion during repair of internal carotid injuries and allow selective revascularization of patients with neurologic deficit and carotid occlusion.

Vascular and orthopedic complications of knee dislocation.

Experience with complete dislocation of the knee in 22 consecutive patients during a six year period was analyzed. Major vascular complications occurred in nine of 13 extremities with anterior dislocation, one of seven extremities with posterior dislocation and none of two extremities with lateral dislocation. Liberal use of trans-femoral ateriography for diagnosis disclosed significant arterial injuries in four of 15 limbs, despite postreduction pedal pulses which were apparently normal. Limb salvage was accomplished in 20 of 21 survivors and in eight of nine with associated vascular complications. All patients demonstrated severe instability of the ligamentous structures of the knee consistent with the type of dislocation. Posterior instability was severe in all patients, an indication of disruption of the posterior cruciate ligament in every instance. Adequate follow-up information was available on 12 knees that had primary ligamentous repair, ten of which were stable to stress testing. Postoperative immobilization was accomplished by external skeletal fixation, skeletal traction or long leg posterior plaster splint.

Civilian popliteal artery trauma: an eleven year experience with 83 injuries.

Limb loss is the outcome in one third of previously reported popliteal artery injuries. This report summarizes 83 injuries with an amputation rate of 9.6%. Penetrating traumas accounted for 61 (73%) injuries and blunt traumas for 22 (27%). The incidence of amputation varied with injury type from none in seven stab wounds to three of 19 (15.8%) shotgun wounds. Distal ischemia or a pulse deficit highlights the presence of arterial trauma, and the external wound defines its site in most patients. Urgent operation is indicated by these findings. Equivocal findings suggest less compromised flow, and such patients are managed best by arteriographic confirmation before operation. Early systemic anticoagulation is indicated to decrease distal small-vessel thrombosis. The successful management of these injuries requires early and complete restoration of arterial and venous flow. This is accomplished most effectively by priority definitive reconstruction. Compulsive attention to complete restoration of arterial flow during the initial procedure is mandatory. Resection or bypass of all damaged arterial wall, liberal use of autogenous vein grafts, and repair of concomitant venous injuries enhance continued arterial patency. Routine distal catheter thrombectomy and frequent intraoperative arteriography promote and confirm complete reconstruction. Early performance of four quadrant fasciotomy is indicated if compartmental hypertension is suspected. Thorough debridement of injured and questionably viable soft tissue and adequate fracture stabilization are integral parts of successful revascularization.

Value of arterial pressure measurements in the proximal and distal part of the thigh in arterial occlusive disease.

A prospective study was carried out comparing two techniques of segmental arterial pressure measurements of the leg to detect, localize and quantify regional arterial occlusive disease. The measurement of pressures of the proximal and distal parts of the thigh with the narrow cuff technique permitted correct anatomic localization of aortoiliac, femoropopliteal or combined disease in 78 per cent of diseased extremities, including all limbs with isolated aortoiliac or femoropopliteal disease. A single wide cuff arterial pressure measurement of the thigh correctly localized arterial obstructions in only 19 per cent of diseased extremities. Although a wide cuff is associated with less artifactual elevation in measured arterial pressure at the thigh, this advantage is outweighed by the limitation of diagnostic accuracy in localizing segmental arterial occlusive disease. We recommend that segmental arterial pressure measurements of the limb be made at four levels on the lower extremity, including arterial pressures of the proximal and distal parts of the thigh to achieve maximal diagnostic accuracy.

Noninvasive assessment of collateral blood flow of the cerebral hemisphere by Doppler ultrasound.

Directional flow in the frontal artery, a terminal branch of the ophthalmic artery, was assessed nonivasively by Doppler ultrasound druing brief digital compression of the ipsilateral common carotid artery in 62 patients. Directional frontal artery flow during carotid compression was compared with mean distal internal carotid back pressure measured at subsequent carotid endarterectomy. Mean carotid back pressure in 28 patients with normal frontal artery flow direction during carotid compression, 68 +/- 14 millimeters of mercury, was significantly higher than that observed in 24 patients in whom frontal artery flow was completely obliterated and ten in whom frontal artery flow was reversed. Distal internal carotid back pressure exceeded 48 millimeters of mercury in all patients with normal frontal artery flow direction during carotid compression. Conversely, carotid back pressure was below 41 millimeters of mercury in all but one patient in whom frontal artery flow was obliterated or bliterated or reversed during carotid compression. The results of this study indicate that Doppler ultrasound assessment of frontal artery flow direction during simultaneous carotid compression provides a rapid, sale noninvasive estimate of the adequacy of collateral hemispheric circulation.

Doppler cerebrovascular examination: improved results with refinements in technique.

Doppler ultrasonic assessment of extracranial carotid occlusive disease has been modified to decrease the incidence of false positive and negative diagnoses. The technique, which assessed directional flow in the frontal artery and the influence of sequential compression of each temporal, infraorbital, facial and common carotid artery, was performed on 152 vessels visualized by contrast arteriography. Presence or absence of significant (greater than 50%) stenosis or occlusion of the internal carotid artery was identified correctly in 150 vessels (98.7%). Inasmuch as the classic temporal artery compression test only detected 39 of the 61 abnormal Doppler studies (64%), the more complete examination is recommended for screening patients for significant carotid artery obstruction.

Value of segmental limb blood pressures in predicting results of aortofemoral bypass.

The efficacy of segmental limb blood pressure measurements, assessed noninvasively by Doppler ultrasound, in predicting the result of aortofemoral reconstruction was evaluated in fifty-two extremities with varying extent of aortoiliac and more distal arterial occlusive disease. Three prognostic correlates were analyzed: (1) preoperative proximal thigh/arm pressure index (TPI); (2) preoperative pressure gradient between adjacent leg segments (proximal thigh, above-knee, below-knee, and ankle), normally less than 30 mm Hg; and (3) early postoperative increase in the ankle/arm pressure index (API). After aortofemoral bypass, forty-one limbs (79 per cent) were asymptomatic or improved and eleven were unimproved. The mean TPI in extremities benefiting from aortofemoral bypass, 0.82 +/- 0.17 (+/-1SD) was significantly less than that of unimproved limbs, 1.01 +/- 0.09 (p less than 0.01). Aortofemoral bypass was beneficial in all twenty limbs with normal leg pressure gradients. Conversely, six of twenty-five legs with one abnormal gradient and five of seven with two abnormal gradients failed to improve. The postoperative increase in API was 0.1 or more in all forty-one improved extremities and was less than 0.1 in all eleven failures. Although eleven of thirty-two limbs (34 per cent) with arteriographic evidence of combined aortoiliac and subinguinal occlusive disease were not improved after proximal bypass, the result of operation could not be predicted from the angiographic pattern or severity of distal disease. Segmental limb blood pressures provide useful predictive indices of the efficacy of aortofemoral bypass and the potential need for more distal reconstruction in multisegmental disease.

Noninvasive ultrasonic carotid angiography: prospective validation by contrast arteriography.

Pulsed ultrasonic images of the carotid bifurcation in 82 vessels of 43 patients were compared independently with contrast arteriograms for stenosis (by percentage quartiles) or occlusion of the internal carotid artery. All 14 occluded vessels were identified correctly by ultrasound but were visualized on repeat examination. Estimation of percentage stenosis on ultrasonic images agreed with the quartile determination by contrast arteriography in 35 of 68 (51 percent) vessels and was within one quartile of correct interpretation in 48 of 68 (71 percent). The interpretative error of grading stenosis of ultrasonic images was due to vascular wall calcification which inhibited ultrasound transmission. This limitation was overcome by sound spectral (sonographic) analysis of distal internal carotid flow velocity which allowed estimation of stenosis within one quartile of that determined by contrast arteriography in 46 of 47 (98 percent) vessels.