Noninvasive flow techniques in the diagnosis of cerebrovascular disease.

The accuracy of oculoplethysmography (OPG) and carotid phonoangiography (CPA) singly and in combination, the Doppler velocity detector, and photoplethysmography (PPG) was checked by measurement of the degree of stenosis as shown on arteriograms in 308 internal carotid arteries. In a second study using arteriographic measurement in 210 internal carotid arteries, the comparative accuracy of the fluid-filled (Kartchner) and the air-filled (Zira) OPG, each with and without CPA, was assessed. In the first study the specificity in arteries with less than 40% diameter reduction varied from 88% for the PPG to 97% for the Doppler examination. The sensitivity in arteries with more than 40% diameter reduction varied from 17% for the Doppler examination to 80% for the combination of OPG plus CPA. For arteries with a reduction in diameter greater than 70%, the sensitivity varied from 67% for the CPA to 87% for the OPG plus CPA. The sensitivity of the OPG plus CPA for total occlusions was 93%. For bilateral carotid artery stenosis over 40%, the sensitivity varied from 50% for the CPA to 82% for the combined OPG plus CPA. In the second study, for arteries with less than 40% stenosis the specificity varied from 86% for the Zira computed readout to 93% for the OPG(K). In the second study, when retrospectively analyzed, the sensitivity for arteries with more than 40% stenosis varied from 74% for the Zira computed readout to 88% for the combined OPG(K) plus CPA. For arteries with greater than 70% diameter reduction the sensitivity varied from 79% for the Zira readout to 100% for OPG plus CPA. For bilateral carotid artery disease with greater than 40% diameter reduction, the sensitivity ranged from 50% for OPG(Z) to 77% for OPG(Z) plus CPA.

Use of umbilical vein graft as an arterial substitute.

Seventy reconstructions, 14 to the popliteal artery above the knee, 40 to the popliteal artery below the knee, and 16 to the tibioperoneal arteries were performed with the Dardik umbilical vein graft tanned in glutaraldehyde. Indications for use included absence of or inadequate saphenous veins, or for expediency during emergency or complex procedures. The cumulative patency rate (calculated by the life table method) for the total group was 77% at 18 months. The failures are further analyzed according to the type of procedure, the grade of disease, and the distal runoff vessel. Early failures were attributed primarily to poor runoff and not to intrinsic properties of the graft. Our overall experience with the umbilical vein graft has been good. Further long-term follow-up is necessary.

Femoral vein reconstruction in the management of chronic venous insufficiency. A 14-year experience.

Clinical, hemodynamic, and venographic studies were performed on 46 patients undergoing reconstruction of the incompetent femoral vein and followed up for 13 years. Operations included 32 valve repairs and 14 vein segment transpositions. Twenty-four patients had perforator vein interruption in addition to valve surgery; 16 had only valve procedures; and six had had previous perforator surgery. The results indicate that ambulatory venous pressure is the most reliable hemodynamic test; it is sensitive but not specific. Descending venography proved the durability of valve repair up to 12 years. Perforator interruption improved the clinical and the hemodynamic outcomes. Good to excellent long-term results were found in 83% of the patients operated on for ulceration and, of those with recurrence, all were seen within the first four postoperative years. Restoration of competence in the femoropopliteal segment produces a long-term favorable effect. Optimal clinical, venographic, and hemodynamic results occur when all abnormal venous divisions (saphenous, perforating, and deep) are corrected.

Extending the vascular examination by noninvasive means.

The Doppler and phleborheographic technics are highly accurate and convenient methods of diagnosing acute deep venous thrombosis, which cannot be detected reliably by clinical examination. Extent of occlusive disease can be more quantitatively estimated by the Doppler method in the peripheral arteries of the limbs and by oculoplethysmography and phonoangiography in the carotid arteries. Noninvasive methods permit screening of patients suspected of arterial or venous disease and provide physicians with an objective means of assessing therapeutic results.

Assessment of chronic venous insufficiency using dynamic venous pressure studies.

In this study, 207 consecutive limbs with chronic venous insufficiency were evaluated with dynamic venous pressure studies and they were correlated with the clinical presentation and results of definitive radiologic studies with ascending and descending venography. Multiple methods of performing the pressure studies, by active exercise, passive manual compression, and tourniquet application at the calf and ankle, proved useful in distinguishing the severity and location of venous disease. The limits of confidence that can be ascribed to the dynamic venous pressure studies were also determined.

Carotid endarterectomy. Controversies and recommendations.

Carotid endarterectomy is a comparatively safe procedure for prevention of stroke in carefully selected patients with carotid stenosis. Generally, it is indicated in patients with hemispheric symptoms of transient ischemic attacks (TIAs), but it is more controversial in patients with non-hemispheric TIA symptoms or no symptoms. Emergency endarterectomy in patients with acute TIA symptoms is considered dangerous. Results of a series of 120 endarterectomies performed at Straub Clinic, Honolulu, confirm the benefits of elective endarterectomy when a meticulous operative technique is followed and intraoperative angiography and repair of defects are done. Prophylactic endarterectomy should not be performed unless a very low incidence (less than or equal to 3%) of combined major morbidity and mortality can be achieved.

Thromboembolism after hip surgery. Comparison of screening methods.

Venous thromboembolism is a serious and, often, asymptomatic complication of hip surgery. A reliable screening test is needed to detect thrombi early to prevent death from pulmonary emboli. Noninvasive screening tests were ineffective in our study of 453 patients. We recommend early use of ventilation/perfusion lung scanning in all patients after hip surgery. In those who have positive results, ascending venography can be used to localize the thrombus and anticoagulation therapy can be started early.

Long-term effects of superficial femoral vein ligation: thirteen-year follow-up.

This study examines the late clinical, hemodynamic, and anatomic results of superficial femoral vein ligation performed in 35 extremities that were followed an average of 13 1/2 years (range, 5 to 22 years). Indications for interruption were to prevent recurrent embolization from distal deep venous thrombosis (14 cases), to prevent emboli in patients with contraindication to anticoagulants (eight cases), to prevent distal reflux in selected patients undergoing iliofemoral thrombectomy (11 cases), and to control reflux in failed venous reconstruction (two cases). Ligation was effective in the prevention of pulmonary emboli as indicated by no significant clinical events and 15 negative postligation ventilation-perfusion scans. Long-term clinical follow-up showed normal (class 0) or near-normal (class 1) extremities in 83%. Fourteen percent developed mild to moderate symptoms of pain or swelling but without ulceration (class 2), and only one case (3%) had ulcerative sequelae (class 3). The only two findings that correlated with worse clinical outcome were the presence of an incompetent profunda femoris or an obstructed greater saphenous vein. Profunda femoris reflux was found in 60% (3/5) of patients with class 2 or 3 sequelae, which was significantly higher than the 14% (3/22) found in those patients with class 0 or 1 results (p < 0.05). Obstruction of the greater saphenous vein was found in 50% of those patients with class 2 or 3 results as opposed to 9% with class 0 or 1 results (p = 0.05). A large collateral vessel between the profunda femoris and the distal superficial femoral or popliteal vein was associated with poor long-term results.(ABSTRACT TRUNCATED AT 250 WORDS)

A method of performing descending venography.

With the recent development of successful methods to correct valve incompetence in the lower extremity, there is a need for a standardized approach to descending venography. This is the single test that accurately defines the site of the venous valve and demonstrates its competence or degree of incompetence. This report describes a technique of descending venography, including the details of catheter placement, injection procedure, and monitoring techniques. Interpretation of the study requires a method that analyzes both the individual valve function and the overall valvular competence of the entire extremity. Descending venography can separate patients with primary valve incompetence from those with postthrombotic valve destruction, as well as the occasional case of valve aplasia. Points on interpretation of valve function and the use of the Valsalva maneuver for "stressing" the valve are discussed. The descending venographic results are compared with the clinical state and with venous pressure findings in 78 extremities.