Ankle pressure changes in distal bypass grafts during knee flexion.

Systolic ankle blood pressure was measured with the limb extended and then acutely flexed in four study groups. These included 11 normal individuals, 11 patients with below-knee autologous saphenous vein bypass grafts, 11 patients with polytetrafluoroethylene (PTFE) prosthetic below-knee bypass grafts, and 11 patients with femoropopliteal arterial occclusion who had not undergone bypass grafting. This study shows that normal limbs, limbs with saphenous vein bypass grafts, arteriosclerotic limbs, and those with PTFE bypass grafts all tolerate acute knee flexion without significant decrease in distal blood pressure.

Rational approach to the differentiation of vascular and neurogenic claudication.

Lower extremity pain caused by exercise but relieved by rest is usually a reliable symptom of chronic arterial insufficiency. However, similar discomfort often occurs in patients with neurospinal compression. Furthermore, arterial occlusive disease and demonstrable spinal stenosis may be present simultaneously. Fifty-two patients with symptoms suggesting intermittent claudication comprised the study group. All were proven to have a nonarterial cause of their complaint. The study consists of a retrospective analysis of the diagnostic methods used in confirming the proper diagnosis. Conclusions reached suggest a rational approach to solution of individual patient problems. The nonvascular origin of the symptoms was suggested initially by clinical evaluation in 19 patients, and by noninvasive arterial evaluation in an additional 22. The neurospinal origin of symptoms was obscured in 11 patients because of the presence of significant arterial occlusive disease, as demonstrated by nominvasive arterial testing. Seven of the 11 patients underwent arterial reconstruction, which failed to relieve their symptoms. Subsequently, the neurospinal origin of these symptoms was proven by appropriate treatment. This experience has shown that the errors in diagnosis and treatment could have been avoided by using a combined diagnostic approach, correlating results of an accurate clinical evaluation with noninvasive arterial testing as well as the findings shown on lumbosacral spine films.

The asymptomatic carotid bruit and the ocular pneumoplethysmography.

Patients with asymptomatic carotid bruits require some noninvasive method for detecting which would benefit from angiography and possible prophylactic operative repair of the suspected atherosclerotic lesion. This report describes the use of the ocular pneumoplethysmograph (OPG) in this regard. Data for establishing OPG criteria of significant carotid stenosis were derived from studies in symptomatic patients who had also undergone angiography. In this review, the OPG demonstrated an accuracy of 91.6% in detecting at least a 75% diameter stenosis. The OPG criteria were applied to 116 patients with asymptomatic carotid bruits. Forty two of the 116 patients fulfilled at least one of the four criteria for angiography. In 38 of the 40 patients who underwent angiography, the OPG findings were confirmed, for an accuracy of 95%. Twenty-two patients underwent 27 operations, without morbidity or mortality.

The collateral hemispheric systolic pressure.

Satisfactory calibrated BP tracings were obtained during 385 (85%) of 455 carotid endarterectomies. The pressures were measured from the distal common carotid arteries while the external carotid arteries were clamp occluded. Continuous recordings were made with and without proximal common carotid clamp occlusion. The two systolic pressures resulting in each patient were plotted as a single point on a graph, with the direct carotid systolic pressure on the abscissa and the back carotid systolic pressure on the ordinate. Formulae of the mean values in 101 of the 385 procedures, in which the opposite carotid systems contained severe stenoses or total occlusions, and the other 284 procedures, in which the opposite carotid systems had no notable lesions, demonstrate that the collateral hemispheric systolic pressure depends on the status of the opposite carotid artery and on the central BP. We derived formulae for these two groups of patients to demarcate the lowest collateral hemispheric systolic pressure adequate for hemispheric integrity during and following prolonged operative carotid occlusion or following permanent interruption of carotid blood flow as a result of thrombosis, ligation, or resection without graft replacement.

Hemodynamic and angiographic guidelines in selection of patients for femorofemoral bypass.

Although crossover femorofemoral grafts have had good long-term patency, all patients have not been symptomatically improved. Seventy-one patients underwent 80 femorofemoral bypasses from 1968 to 1978. Hemodynamic assessment included preoperative and postoperative segmental Doppler pressures and femoral artery waveform recordings. Preoperative and selective postoperative arteriography was routinely performed. Twenty-nine failures occurred predominantely in two groups, those with greater than 50% stenosis of the donor iliac artery and those with severe recipient limb outflow occlusive disease. Ten patients with normal outflow beds bilaterally associated with 10% to 50% stenosis of the donor iliac artery underwent successful femorofemoral reconstruction. Progression of donor iliac artery disease was seen in only two patients. Cumulative five-year patency was 74%. Operative mortality totaled three (3.8%). This study supports the use of femorofemoral bypass as a primary procedure when proper guidelines are used.

Technique for thrombectomy of reversed saphenous vein arterial bypass grafts.

A technique for thrombectomy of saphenous vein arterial bypass grafts is described. The technique includes visual inspection of both anastomoses and avoids unnecessary trauma to the graft secondary to repeated attempts at passing a balloon catheter against the direction of the venous valves.

Free-tissue transfers for limb salvage utilizing in situ saphenous vein bypass conduit as the inflow.

Using vein grafts to bypass sclerotic and occluded arterial segments is a well-established technique in vascular surgery. For infrapopliteal bypass, autogenous veins have better patency rates than synthetic grafts. Although not resolved, in situ bypasses seem to be better than reversed bypasses, especially for "far away" segments. Although the etiology is not understood, it is a well-known clinical finding that sclerosis affects arteries more than the veins and, as a whole, is more advanced in lower extremities compared with the trunk and upper extremities. Our experience with eight patients in whom critical soft-tissue defects were covered with free-tissue transfers in severely compromised lower extremities utilizing the in situ saphenous vein bypass as the inflow is presented. Simultaneous bypass and free-tissue transfers were performed in seven and delayed free-tissue transfer was done in one. Follow-up ranged from 6 months to 3 years. To date, two patients underwent amputations. Five patients are able to maintain bipedal ambulation. One patient is wheelchair-bound with intact lower extremities. In well-selected patients, this procedure may offer an alternative treatment to amputation. However, because of the complexity of these combined procedures, we strongly urge careful patient selection.

Operative hemorrhoidectomy versus cryodestruction.

Twenty-six patients were treated for hemorrhoids by a combination of cryodestruction and closed operative hemorrhoidectomy. Patients were able to draw their own conclusions about the efficacies of these treatments. They had no difficulty in distinguishing exactly which area was causing pain. The operative site was a source of greater pain until the second day after the procedure, when the pain resulting from cryodestruction equalled surgical pain; then cryodestruction associated pain continued longer. Cryodestruction was associated with production of a foul discharge. Residual hemorrhoids were present in 50 per cent of patients' cryodestruction sites. Given the choice at the one year follow-up examination, 65 per cent preferred surgical treatment and 35 per cent preferred cryodestruction.

Summary of cases of adventitial cystic disease of the popliteal artery.

Adventitial cystic disease of the popliteal artery is explored. The results of correspondence with authors reporting this condition are elaborated upon. This has provided an opportunity to discuss the history of the condition, the findings in 115 cases which have come to the attention of the Correspondence Office dealing with this entity, and the results of treatment. A discussion of the suspected etiology of the condition is presented. The condition remains one of unknown etiology which can be treated by cyst evacuation or aspiration when the popliteal artery is patent and which is best treated by arterial reconstruction when the artery is occluded. The results of such treatment are good but are dependent upon technical excellence of the operative procedure.

Efficacy of preoperative and postoperative bone scanning in the management of breast carcinoma.

With use of 99mtechnetium-labeled phosphates, we performed preoperative bone scans on 122 women with biopsy-proved breast carcinoma. Only two of the 110 patients with Stage I or II disease had scan abnormalities interpreted as bone metastases. Of 55 patients with normal preoperative scans, 20 later had changes suggesting bone metastases on the subsequent scans, most within 24 months of operation. In women with Stage I and II tumors, 13 of 48 (27 per cent) had scan evidence of bone metastasis of postoperative follow-up examination. Five of 23 with potential surgical cures (negative lymph nodes at operation) had bone metastasis within two years of operation. In Stage I and II patients, postoperative discovery of evolving metastases was most often (11 to 13) made by bone scan. Although the initial yield from preoperative bone scans is low, preoperative scanning combined with sequential postoperative scans constitutes one of the most sensitive indicators of evolving metastatic disease.

Accessory nerve injury during carotid endarterectomy.

Injury to the accessory nerve (cranial nerve XI) during carotid endarterectomy is rare; to date only three cases have been reported in the literature. Traction on the sternocleido-mastoid muscle was the proposed mechanism of injury in all three cases. Four cases of accessory nerve palsy occurred in 850 carotid endarterectomies performed between 1978 and 1986 at this institution, an incidence of 0.47%. All four patients had classic signs and symptoms of accessory nerve injury, which developed between 20 and 60 days after operation. The three most recent cases were examined specifically for accessory nerve injury in the immediate postoperative period and exhibited normal trapezius function. None had any other central nervous system dysfunction. Two of these patients regained full accessory nerve function and the most recent case is showing signs of reinnervation with conservative therapy. Isolated central nervous system and spontaneous accessory nerve palsies are exceptionally rare, and since any traction injury or transection should have been detected by postoperative examinations in three of four patients, we propose surgical scar formation as a mechanism of accessory nerve palsy after carotid endarterectomy. If such a palsy develops in the postoperative period, we recommend conservative therapy.

Splenic infarction caused by a large thoracic aortic thrombus.

We report on a patient with left upper quadrant pain as a result of splenic infarction; the patient was subsequently found to have a thoracoabdominal aortic thrombus extending through the celiac axis. The patient was successfully treated with an aortic thrombectomy guided by intraoperative transesophageal echocardiography.

Carotid endarterectomy: a follow-up study of the contralateral non-operated carotid artery.

In a study of 103 patients surviving carotid endarterectomy, follow-up information was obtained from all patients over a period of time extending to four years. This was done so that better decisions could be made regarding recommendations for contralateral carotid surgery. In this follow-up study, only three patients had contralateral surgery. Three additional patients had events clearly in the territory supplied by the contralateral carotid artery, and no patient suffered a contralateral stroke. There were an additional four patients who suffered stroke in territory not supplied by the contralateral carotid artery. In addition, four patients experienced classical transient ischemic episodes referrable to the operated carotid artery and ten patients experienced nonclassical cerebral ischemia. Seven of the 103 patients died at times remote from the carotid surgery of nonstroke cause.

Vascular-laboratory diagnosis of clinically suspected acute deep-vein thrombosis.

Doppler ultrasound, impedance plethysmography, and contrast venography were performed in 207 lower limbs suspected of harbouring deep-venous thrombosis, to clarify the diagnostic value and limitations of the non-invasive methods. Doppler ultrasound and impedance plethysmography were accurate in 96% and 95% of normal limbs, respectively. In limbs with venographic evidence of thrombosis requiring treatment, Dopper ultrasound and impedance plethysmography correctly detected thrombosis in 60% and 97%, respectively. Doppler ultrasound was 97% accurate in recognising chronic venous insufficiency. Impedance plethysmography was incorrectly positive in 74% of limbs with chronic venous insufficienv cy which had no venographically detected thrombosis. These findings suggest that, for the accurate diagnosis of clinically suspected deep-vein thrombosis, venography is necessary only in patients with chronic venous insufficiency who have normal Doppler ultrasound tests and abnormal impedance plethysmograms and in patients with abnormal cardiac haemodynamics. In this series, 86% of limbs would have been spared venography had non-invasive tests been used. Venography, however, remains the standard test for the detection of minor calf-vein thrombosis. A diagnostic and therapeutic schema is proposed.