Radiation-induced arterial injuries.

In a 20-year period from 1961 to 1981 at the University of Kentucky Medical Center, there were 20 patients with vascular lesions directly attributable to irradiation. Two distinct patterns of arterial injury attributable to radiotherapy were identified--arterial disruption and occlusion. Arterial disruption occurred in 12 patients--11 carotid blowouts and 1 iliac artery rupture. Two patients underwent prophylactic carotid artery ligation for impending rupture. In the 11 carotid artery ruptures, ligation of the artery in nine patients resulted in stroke or death in five patients. Iliac artery disruption necessitated ligation, which eventually led to severe ischemia requiring hip disarticulation. Unusual arterial stenosis or occlusion occurred in six patients 7 to 24 years after irradiation. Three patients had severe stenosis or occlusion of the common, internal, or external carotid arteries leading to cerebrovascular insufficiency. Three other patients with focal stenosis of the iliofemoral region were successfully treated with bypass grafting.

Atherosclerosis in the young: a virulent disease.

To learn more about the prognosis of young patients with atherosclerotic cardiovascular disease we reviewed our experience with patients 40 years of age or younger who required surgical intervention for cardiovascular occlusive disease. We identified 47 patients, 25 of whom required peripheral vascular reconstruction and 22 of whom underwent coronary artery bypass grafting. All but one patient were extremely heavy cigarette smokers. Of the 11 women with peripheral vascular disease, eight required operations for limb salvage and three for renovascular hypertension. Four of the 11 women required a total of 11 subsequent operations because of recurrent or progressive disease. Of the 14 men, 13 required intervention for limb salvage and one for renovascular hypertension. Forty-five additional operations, including 15 amputations, were required in these 14 male patients because of recurrent or progressive disease. Of the 22 patients (21 men and one woman) who underwent coronary artery bypass operations, there was one postoperative death. Five patients (23.8%) required a second bypass operation and one patient (4.8%) required a third procedure bypass because of recurrent symptoms and occluded grafts. One patient has occluded grafts and inoperable disease. Atherosclerotic cardiovascular disease in young patients appears to be a virulent disease process and is associated with a high rate of recurrent or progressive disease. There is a striking association between the premature development of atherosclerotic cardiovascular disease and cigarette smoking.

Effects of atherosclerosis on the cutaneous regional and microcirculatory response to ischemia.

The cutaneous vascular response to gravity load is abnormal in atherosclerosis. In this study we compared the macrocirculatory and microcirculatory response to ischemia in atherosclerotic smokers, nonatherosclerotic smokers, and healthy nonsmokers. Using videodensitometry, the capillary blood velocity of hallux nail fold capillaries was measured at rest and following 1 minute of ankle cuff occlusion. Blood-flow velocity of the dorsal metatarsal artery was measured by ultrasound Doppler. Resting dorsal metatarsal artery velocity and capillary blood velocity of atherosclerotic subjects were lower than those of nonatherosclerotic smokers and nonsmokers. The dorsal metatarsal artery velocity and capillary blood velocity increased in each group following occlusion. Peak postocclusion dorsal metatarsal artery velocity was lower in the atherosclerotic subjects, but peak capillary blood velocity was not significantly different among groups. Atherosclerosis does not alter the mechanisms of reactive hyperemia in either the macrocirculation or the microcirculation. The magnitude of hyperemia is diminished at the macrocirculatory level.

Pentoxifylline increases extremity blood flow in diabetic atherosclerotic patients.

Pentoxifylline, a new trisubstituted methylxanthine derivative known for its hemorrheologic action, has been shown to improve exercise tolerance in atherosclerotic patients. We examined the responses of diabetic atherosclerotic patients to pentoxifylline administration, measured by Doppler waveform analysis and exercise tolerance. Standard exercise tolerance and Doppler waveform analytic studies of the lower extremity, specifically the right dorsalis pedis artery, were performed before and after three months of pentoxifylline administration (400 mg three times a day). The study group comprised ten subjects (six men and four women) with a mean (+/- SD) age of 60 +/- 3.3 years. Data were analyzed using a paired Student t test. All ten subjects showed a significant increase in exercise tolerance after pentoxifylline treatment. Eight of ten subjects demonstrated a significant increase in right dorsalis pedis arterial flow.

Alcohol and drug use by surgery residents.

BACKGROUND: Although the use of alcohol and drugs by surgery residents is of concern, no large-scale studies of this specific population exist. STUDY DESIGN: A one-page, 36-item questionnaire on frequency of use of alcohol and drugs was administered to residents at the conclusion of the American Board of Surgery In-Service Examination. RESULTS: The survey showed that the use of drugs by surgery residents is relatively low when compared to drug use by other physicians. However, alcohol abuse continues to be a problem, and alcohol is the drug of choice of most residents. Cocaine used by surgery residents is generally obtained from hospital sources. CONCLUSIONS: Despite the optimistic findings of the survey, the authors advocate the following: Implementation of educational programs to prevent potential abuse of alcohol and drugs, and establishment of tighter controls on cocaine or use of a cocaine substitute for patient care.

Nontraumatic lower-extremity acute arterial ischemia.

BACKGROUND: The outcome of arterial bypass reconstruction in the setting of acute arterial ischemia has not been well defined. METHODS: This retrospective review consists of 71 consecutive patients (54 with native arterial thrombosis, 17 with graft thrombosis) who underwent an urgent/emergent arterial bypass reconstruction for acute arterial ischemia with threatened limb viability. RESULTS: The 30-day mortality and major amputation rates were 9.9% and 7.1%, respectively. Death, limb loss, or both, were associated with a paralytic limb (P = 0.001) and congestive heart failure (P = 0.03). Overall, 45 of 71 (63%) patients were discharged with limb salvage and ambulatory function. Cumulative graft patency was 77% and 65% at 1 and 2 years, respectively, and closely approximated the 1- and 2-year limb-salvage rates of 76% and 63%, respectively. CONCLUSIONS: Arterial bypass reconstructions appear warranted in acute arterial ischemia, in that a majority of patients retain a functional viable limb. Late graft thrombotic complications limit long-term benefit.

Femoral artery profundaplasty.

In advanced ischemia of the lower extremity, the deep femoral artery is rarely completely occluded, but may have a hemodynamically significant occluding plaque at its origin. Detection of this lesion requires biplanar arteriographic views. As indicated in this report, the related simple procedure of femoral artery profundaplasty may salvage limbs and lower amputation sites, and it is suitable for poor risk patients.

Carotid endarterectomy results from a state vascular society. Kentucky Vascular Surgery Society Study Group.

PURPOSE: This study analyzes the results of carotid endarterectomy (CEA) performed statewide by members of the Kentucky Vascular Surgery Society (KVSS). METHODS: Between September 1, 1991 and September 1, 1993, 22 vascular surgeons in the KVSS submitted 1490 CEAs to the vascular registry. Follow-up data were obtained on 986 (66%) CEAs performed on 889 patients (average age, 68 years). RESULTS: Carotid endarterectomy was performed on 505 men and 384 women. Indications for operation were asymptomatic carotid stenosis (43%), transient ischemic attack (TIA; 27%), amaurosis fugax (13%), stroke (11%) and nonhemispheric symptoms (6%). A total of 384 cases had primary closure, and 602 had patch reconstruction following CEA. The combined stroke-mortality rate was 2.3% (10 strokes and 13 deaths). The combined stroke-mortality rate of CEA was 2.1% for patients treated by academic surgeons and 2.3% for those treated by community surgeons. Deaths were due to stroke (4), sepsis (5), cardiac complications (2), intracerebral hemorrhage (1) and cancer (1). Five patients had postoperative TIAs. After CEA, duplex scan surveillance was performed in 629 (64%) patients, with 23 (3.6%) residual/recurrent stenosis (10, 50%-75%; 13, 75%-99%) detected; 5 undergoing reoperation. CONCLUSIONS: These data support the efficacy and safety of CEA performed by a large number of vascular surgeons in both community and academic practice.

Peritoneal venous shunting for ascites: a 15-year perspective.

Intractable ascites is an incapacitating condition for the patient and a difficult management problem for the physician. Three different shunts have been evaluated in 26 patients over a 15-year period and, on the basis of this experience, recommendations are made to avoid some of the technical problems with peritoneal venous shunts. Nine patients had a Hyde shunt, 12 had a LeVeen shunt, and five patients had a Denver shunt. Operation was performed only after failure of medical management during a 2-24-week period of hospitalization. Four patients had malignant ascites, two nephrogenic ascites, and the remaining 24 patients had ascites secondary to alcoholic liver disease. The type of shunt used did not appear to be critical, as the results were similar in the three groups. The morbidity rate of 57% (operative deaths and need for revision) and the fact that only 27% were alive after one year emphasize that improvements are desirable. Methods to avoid technical problems influencing malfunction of the device are stressed.

Compartment syndromes. Early diagnosis and a bedside operation.

Delays in diagnosis and treatment of compartment syndromes of the lower extremities result in significant morbidity and mortality. Knowledge of the anatomy of the lower leg compartments provides clues to earlier diagnosis as to the specific compartments involved in these syndromes. A simple physical examination is described that focuses on this. Furthermore, a simple "bedside" operation is described that provides excellent decompression of all of these compartments without fibulectomy.

Mucinous cystic neoplasm of the pancreas with latent malignancy.

Mucinous cystic neoplasms of the pancreas are rare. They have traditionally been classified as cystadenoma or cystadenocarcinoma. Over a 5-year period, and three operations, a patient initially diagnosed as having a cystadenoma of the pancreas was subsequently found at the time of definitive total pancreatectomy to have a cystadenocarcinoma. The recent literature suggests that there is not distinction between cystadenoma and cystadenocarcinoma, since these tumors have been shown to contain coexisting areas of malignant and benign epithelium in both types. The authors' experience with this patient demonstrates the necessity for thorough histologic sectioning of these tumors to document the presence of carcinoma, since all of these tumors should be regarded as potentially malignant neoplasms. Surgical therapy for these lesions should be total excision whenever feasible.

Popliteal artery thrombosis associated with trampoline injuries and anterior knee dislocations in children.

Recent reports have emphasized the benign nature of trampoline-associated injuries. However, this study describes the limb-threatening problem of popliteal artery thrombosis occurring in association with anterior knee dislocation and trampoline injuries. Three children (ages 11, 13, and 17) were referred to the emergency room within the past 12 months with anterior dislocations of the knee, which occurred while jumping on trampolines. All patients had reduction of their dislocations at outside facilities and were referred within 6 to 12 hours after their injuries, with pulse, motor, and sensory deficits. All patients were taken directly to the operating room, where arteriography confirmed thrombosis of the popliteal artery below the knee. One patient had transection of the artery, whereas two patients had stretch injuries with intimal separation. Each patient required interposition grafting with reversed saphenous vein and underwent concomitant four-compartment fasciotomy. All patients had persistent sensory and motor deficits postoperatively, which were presumed to be a combination of ischemic injury and neuropraxia. All patients have functioning grafts with an average follow-up of 1 year (range, 9-15 months). One patient required a second interposition graft to treat an area of intimal hyperplasia, which developed at the proximal anastomosis, at 6 months postoperatively. Eighty per cent of trampoline injuries are associated with minor injuries with minimal long-term complications. However, dislocations of the knee may be associated with significant arterial injury and amputation rates of up to 30 per cent in many blunt trauma series. Based on our experience, physicians should recognize the possibility of significant arterial injuries occurring in children with anterior knee dislocations while jumping on trampolines.

Thallium redistribution does not predict perioperative cardiac complications following vascular surgery.

Utility of preoperative stress thallium scintigraphy (STS) was determined in 59 patients, thought to be at increased risk, prior to major vascular surgery from July 1987 to February 1990. Forty-seven had oral dipyridamole and 12 underwent exercise STS. Thallium redistribution (TR) was present in 61% (n = 36); fixed defects were present in 59% (n = 35); and some combination of defects was present in 76% (n = 45). Perioperative cardiac complications (CC = congestive heart failure [n = 3], ventricular arrhythmia [n = 2], and MI [n = 1]) were present in 8.5% (6 CC in 5 patients). Incidence of CC was 8.3% (3/36) in those with TR, and 8.7% (2/23) without TR (relative risk = 0.95). Perioperative MI was present in 2.8% (1/36) with TR vs. 0% (0/23) without. Though mortality was 3.4%, no perioperative deaths were from cardiac disease. Utility of STS is not clearly established for prediction of perioperative cardiac risk after major vascular surgery.