Muscular, renal, and metabolic complications of acute arterial occlusions: myonephropathic-metabolic syndrome.

Acute arterial occlusions of the extremities may result, in approximately 7.5% of cases, in a severe and complex metabolic syndrome which often leads to loss of limb and life. The manifestations of this syndrome are divided into two stages: (1) the ischemic or devascularization phase, and (2) the revascularization phase. The ischemic phase includes severe clinical manifestations, of which the rigidity of the limb ("rigor mortis") is an outstanding sign, as are nephropathic-metabolic changes (oliguria, acidosis, myoglobinuria, azotemia, hyperkalemia). Their identification and correction at this phase may minimize their impact on the revascularization syndrome. The clinical and metabolic manifestations during the latter phase are more severe and may determine the outcome of the viability of the limb and the survival of the patient. Amputation rates are quite high (40% to 50%) and mortality rates range between 30% and 80%. The ischemic rhabdomyolysis appears to be the initiating event which leads to the biochemical and metabolic alterations that dominate the prognosis as to limb and life. The guiding principles of the management in these severe ischemic cases consist of early revascularization with emphasis on concurrent fasciotomy, alkalinization of the patient, reestablishment of acid-base balance, hemodialysis for renal shutdown, and often early amputation for better control of the metabolic omplications.

Role of precapillary arteriovenous shunting in the pathogenesis of varicose veins and its therapeutic implications.

The conventional pathogenesis of varicose veins and their subsequent development is essentially based on primary valvular insufficiency of the main saphenous trunk and incompetence of the perforating veins. In contrast, the concept of the pathogenesis of varicose veins presented in this review is based on the presence of arteriovenous (AV) shunting that occurs primarily in the venous tributaries and rarely in the main trunks of the saphenous system. Identification of arteriovenous communications (AVCs) with varicose veins has been documented by visual observation during surgery and especially by use of high-powered microscopes or magnifying lenses. The AVCs have been found consistently to originate subfascially and to terminate in tributaries extrafascially, thus bypassing the capillary network. By means of serial arteriography it was shown that in more than 80% of varicose veins there is premature venous opacification. By means of Doppler ultrasonography, it was demonstrated that AV shunting was present in 80% of the cases. A correlative study of these parameters has shown that the initial significant pathology in varicose veins is mostly confined to the tributaries, although at an advanced stage the main trunk may also be subsequently affected to a lesser degree. In terms of management, these data strongly imply that sclerotherapy or surgical treatment (ligation or excision) should be confined to the tributaries and that high saphenofemoral ligation and stripping should be avoided except in cases where evidence shows valvular involvement and incompetency of the latter. As a result, this study strongly suggests that one could most often spare the main trunk of the saphenous vein for eventual use as a vascular graft.

Celiac artery aneurysmectomy: case report with review of the literature.

A case of celiac trunk aneurysm treated by excision and direct reanastomosis with restoration of arterial continuity, and a description of a new technique for selective visualization of the celiac artery are reported. A review of the literature with tabulation of all surgically treated cases is included. Significance of hepatic artery flow restoration is emphasized.

New approaches to limb salvage by extended extra-anatomic bypasses and prosthetic reconstructions to foot arteries.

Because our femoropopliteal reconstructions with expanded polytetrafluorethylene (PTFE) and saphenous vein have comparable patency rates up to 22 months, we used this prosthetic for longer, more complex bypasses for limb salvage. Fourteen axillopopliteal or cross-over axillopopliteal bypasses were performed largely because groin infection or deep femoral artery disease precluded standard procedures; 12 are patent up to 14 months. Five patients required a bypass from one femoral artery to an opposite leg artery; four are patent up to 17 months. Because of progressive necrosis, eight patients required a secondary extension from a femoropopliteal bypass to a distal artery; five are patent up to 12 months. Three patients required extra-anatomic bypass for leg or popliteal space infections; all achieved limb salvage up to 12 months. Twenty patients without other suitable proximal arteries required a bypass to the dorsalis pedis or anterior tibial artery at the ankle; 10 are patent up to 14 months. Eleven patients required posterior tibial bypass at or below the ankle; seven are patent up to 18 months. One postoperative death followed these 61 procedures. Thus these operaions with long PTFE grafts that cross multiple joints can salvage limbs for important periods of time with low risk.

Staging of arterial complications of cervical rib: guidelines for surgical management.

Subclavian artery compression by a cervical rib is an uncommon but potentially disabling condition. A series of 12 patients with 15 arterial lesions is reviewed and a staging system proposed to provide guidelines for managing patients with this condition. Stage I lesions have only arterial stenosis and minor poststenotic dilatation and are managed by thoracic outlet decompression, usually consisting of cervical rib resection. Stage II lesions have intrinsic arterial damage usually with subclavian aneurysm formation and require rib resection, aneurysmectomy, and arterial reconstruction. Stage III lesions present with distal thromboembolic complications and require thrombectomy or embolectomy in addition to thoracic outlet decompression and arterial reconstruction. The anatomic and pathophysiologic bases of the syndrome are reviewed and clinical and angiographic examples of each stage are presented.

Congenital microarteriovenous shunts. Angiographic and Doppler ultrasonographic identification.

We describe herein two cases of vascular malformations, one classified as hemangioma and the other as Klippel-Trenaunay syndrome. Clinical investigation in each case failed to demonstrate the presence of arteriovenous (AV) shunting. Arteriographic findings revealed only indirect evidence of AV shunting in each case. In contrast, systematic scanning with a Doppler ultrasonographic probe of the involved extremities provided evidence of AV shunting and pinpointed it in suspected arteriographic areas. Good correlation between the two methods was confirmed in the hemangioma case both preoperatively and intraoperatively. In the case of Klippel-Trenaunay syndrome, evidence of multiple AV shunts was obtained primarily with Doppler ultrasonography. In addition to arteriography, serial phlebography, when indicated, is also necessary for complete evaluation of concomitant venous malformations. The pathogenic mechanism of these vascular malformations was briefly reviewed, emphasizing AV shunting as a common link between the various anatomicoclinical forms.

Metabolic complications of acute arterial occlusions.

Metabolic complications secondary to acute arterial occlusions occurred in 7.5% of our cases. It is pointed out that the characteristic biochemical changes: 1) may already be detectable during the ischemic phase, and 2) are more pronounced after revascularization of the extremity. Their identification at the early stage is essential for preventing the serious outcome of the late stage. Amputation rates are quite high (40-50%) and mortality rates are similarly great (30-80%). The ischemic rhabdomyolysis which leads to the clinical and manifestations and biochemical alterations is the initiating pathogenic factor of this syndrome. Prophylaxis and management of these complications were reviewed.

Arterial thromboembolism of the upper extremity associated with the thoracic outlet syndrome.

Acute arterial thromboembolism of the upper extremity associated with the thoracic outlet syndrome is much less frequent than the neurologic manifestations, but is a potential threat to the viability of the limb if not recognized in time. The thromboembolic process originates in a damaged subclavian artery as a result of its prolonged compression, usually by congenital, much more rarely, by acquired anomalies of anatomical structures at the thoracic outlet. Major embolic complications usually occur after months or years of episodal and repetitive microemboli. A comprehensive arteriographic evaluation of the entire arterial tree in addition to other tests is essential for diagnosis. Four patterns of arterial findings are described. The scope of the surgical treatment of these manifestations it twofold: (1) decompression of the subclavian artery and (2) repair of the arterial lesions, often with additional thoracic sympathectomy. Results of management of the arterial lesions are described in three groups, based mostly on a review of data from the literature. In recent years a more aggressive approach to these lesions appears to have resulted in better management of this complex entity. A case report will illustrate some the clinical and pathological aspects of this problem. Early recognition of this unusual thromboembolic process is necessary for achieving a more complete limb salvage.

Cardiogenic embolism of the upper extremity.

Arterial embolism of the upper extremity is not as rare and especially not as benign in all instances as was considered in the past. Postembolic ischemic changes or frank gangrene of fingers or hand may occur in a substantial percentage of patients. This paper will attempt to update the current concepts of this problem. The clinical data and the methods for evaluation of the degree of viability of the hand or forearm will be reviewed. Arteriography is recommended more liberally than in the past. Arterial embolectomy usually performed under local anesthesia is widely applicable in view of the simplicity, safety and effectiveness of the balloon catheter technique. The overall results based on a compilation from six reports indicate that complete circulatory restoration occurred in 55% and salvage without a return of wrist pulses in 24%. Gangrene occurred in 9.3% and mortality in 11.8%. In general, mortality following embolectomy is primarily related to the gravity of the cardiopathy and least to the surgical procedure.

Comparison of expanded PTFE and vein grafts in lower extremity arterial reconstructions.

Polytetrafluoroethylene (PTFE) bypasses were used in a series of arterial reconstructions to the popliteal artery (45) and to arteries below that level (11). These were performed in high-risk situations in patients who lacked a suitable saphenous vein. Vein bypasses were performed in a comparable series of high-risk situations in patients having a suitable autologous saphenous vein (45 to the level of the popliteal artery and 11 to an artery below that level). PTFE patency rates at 4-14 months were 43 to 45 (96%) for the femoro-popliteal reconstructions (with a limb salvage rate of 39 to 45 or 87%) and 5 of 11 (45%) for the distal bypasses. Saphenous vein bypass patency rates at 8-14 months were 39 of 45 (87%) for the femoropopliteal reconstructions (with a limb salvage rate of 36 of 45 or 80%) and 5 of 11 (45%) for the distal bypasses. These results justify continued use of PTFE grafts in patients without saphenous veins who require lower extremity arterial reconstructions for limb salvage. The exact place of PTFE grafts in arterial reconstructive surgery of the lower extremity definition based on longer periods of observation.