Noninvasive localization of arterial occlusive disease: a comparison of segmental Doppler pressures and arterial duplex mapping

PURPOSE

The purpose of this study was to compare the abilities of arterial duplex mapping and segmental Doppler pressures to noninvasively localize hemodynamically significant lower extremity arterial occlusive disease.

METHODS

After angiographic controls were instituted, arterial duplex mapping and segmental Doppler pressures were blindly compared for their ability to localize a high-grade (50% to 100%) stenosis to the iliac or common femoral arteries, the superficial femoral artery, or the popliteal artery in 151 lower extremities from 79 patients.

RESULTS

Rates of sensitivity and specificity of arterial duplex mapping for identifying a high-grade stenosis at the three arterial levels were 88% and 97%, 95% and 100%, and 78% and 99%, respectively. Those for segmental Doppler pressures were 59% and 86%, 73% and 80%, and 48% and 53%, respectively. There was complete agreement between arterial duplex mapping and angiography in 82% of the limbs studied and between segmental pressures and angiography in 34% of the limbs (p < 0.0001). The presence of diabetes, kidney failure, or previous vascular surgery in the limb studied did not affect the accuracy of either test.

CONCLUSION

Arterial duplex mapping is far superior to segmental Doppler pressures for localization of high-grade angiographic lesions from the iliac to the popliteal arteries.

Mesenteric duplex scanning: a blinded prospective study

PURPOSE

Based on retrospective comparisons of duplex scanning with arteriography of the celiac (CA) and superior mesenteric (SMA) arteries in 34 patients, we previously suggested that an SMA peak systolic velocity of 275 cm/sec or greater or no flow signal and a CA PSV of 200 cm/sec or greater or no flow signal were reliable indicators of a 70% or greater angiographic stenosis of the SMA and CA, respectively. We now report the results of a blinded, prospective study in a larger patient group designed to determine the ability of mesenteric duplex scanning to visualize the CA and SMA and to validate our proposed duplex criteria for splanchnic artery stenosis.

METHODS

During an 18-month period 100 patients admitted to our vascular surgery service for aortography underwent routine mesenteric artery duplex scanning and lateral abdominal aortography regardless of abdominal symptoms. The lateral aortograms were evaluated to determine the presence or absence of a 70% or greater stenosis in the CA or SMA. Duplex-determined peak systolic velocities from the CA and SMA were recorded without knowledge of the angiographic results.

RESULTS

Aortography satisfactorily visualized 100% of the CAs and 99% of the SMAs. Of these, 93% of the SMAs and 83% of the CAs were visualized by duplex. According to the above criteria, duplex sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy for detection of a 70% or greater SMA stenosis were 92%, 96%, 80%, 99%, and 96% and for a 70% or greater CA stenosis 87%, 80%, 63%, 94%, and 82%.

CONCLUSIONS

Mesenteric duplex scanning is feasible in the majority of patients. Prospective evaluation of duplex diagnostic criteria for 70% or greater stenosis indicates that mesenteric duplex scanning is sufficiently accurate to be clinically useful as a screening examination to detect SMA and CA stenosis.

Mesenteric duplex scanning: a blinded prospective study

PURPOSE

Based on retrospective comparisons of duplex scanning with arteriography of the celiac (CA) and superior mesenteric (SMA) arteries in 34 patients, we previously suggested that an SMA peak systolic velocity of 275 cm/sec or greater or no flow signal and a CA PSV of 200 cm/sec or greater or no flow signal were reliable indicators of a 70% or greater angiographic stenosis of the SMA and CA, respectively. We now report the results of a blinded, prospective study in a larger patient group designed to determine the ability of mesenteric duplex scanning to visualize the CA and SMA and to validate our proposed duplex criteria for splanchnic artery stenosis.

METHODS

During an 18-month period 100 patients admitted to our vascular surgery service for aortography underwent routine mesenteric artery duplex scanning and lateral abdominal aortography regardless of abdominal symptoms. The lateral aortograms were evaluated to determine the presence or absence of a 70% or greater stenosis in the CA or SMA. Duplex-determined peak systolic velocities from the CA and SMA were recorded without knowledge of the angiographic results.

RESULTS

Aortography satisfactorily visualized 100% of the CAs and 99% of the SMAs. Of these, 93% of the SMAs and 83% of the CAs were visualized by duplex. According to the above criteria, duplex sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy for detection of a 70% or greater SMA stenosis were 92%, 96%, 80%, 99%, and 96% and for a 70% or greater CA stenosis 87%, 80%, 63%, 94%, and 82%.

CONCLUSIONS

Mesenteric duplex scanning is feasible in the majority of patients. Prospective evaluation of duplex diagnostic criteria for 70% or greater stenosis indicates that mesenteric duplex scanning is sufficiently accurate to be clinically useful as a screening examination to detect SMA and CA stenosis.

Correlation of North American Symptomatic Carotid Endarterectomy Trial (NASCET) angiographic definition of 70% to 99% internal carotid artery stenosis with duplex scanning

PURPOSE

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) has thus far demonstrated conclusive benefit for carotid endarterectomy for patients with symptomatic 70% to 99% internal carotid artery (ICA) stenosis. In the NASCET, ICA stenosis was classified angiographically: % ICA stenosis = (1 - [narrowest ICA diameter/diameter normal distal cervical ICA]) x 100%. However, widely used duplex scan criteria for ICA stenosis correlate with different angiographic categories of high-grade stenosis (50% to 79%, > 80%) and were developed on the basis of estimated bulb diameter. We therefore blindly evaluated with separate observers carotid angiograms from 100 patients who also underwent carotid duplex scanning in our vascular laboratory.

METHODS

"Angiographic stenosis" was calculated as in NASCET. Duplex scan measurements of ICA peak systolic velocity (PSV), ICA end-diastolic velocity, and the ratio of ICA PSV to common carotid artery (CCA) PSV were analyzed for sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy to identify a 70% to 99% ICA stenosis.

RESULTS

Analysis of the data revealed that an ICA PSV/CCA PSV ratio of 4.0 provided the best combination of sensitivity (91%), specificity (87%), positive predictive value (76%), negative predictive value (96%), and overall accuracy (88%) for detection of a 70% to 99% stenosis.

CONCLUSION

We conclude duplex scan determination of 70% to 99% stenosis as defined in the NASCET requires the adoption of duplex criteria modified from those in current use in most vascular laboratories.

Upper extremity arterial bypass distal to the wrist

Seventeen arterial bypass procedures distal to the wrist have been performed in 13 men and two women at the Oregon Health Sciences University during the past 9 years. Ten patients had traumatic true or false aneurysms of the ulnar artery with digital embolization. Five patients with end-stage renal disease had severe hand and finger ischemia manifested by rest pain or digital ulceration resulting from widespread forearm and hand arterial occlusions. Patients with aneurysms of the ulnar artery underwent excision and reversed autogenous vein grafting (n = 11) from the distal ulnar artery in the forearm to the superficial palmar arch. All the patients with end-stage renal disease had severe occlusive disease of the forearm and hand arteries and underwent a variety of procedures including radial-radial bypass (n = 2), ulnar-ulnar bypass (n = 2), radial-radial bypass with takedown of a Brescia-Cimino fistula (n = 1), and brachial-radial bypass (n = 1). High-quality upper extremity and magnification hand arteriography was essential for operative planning and was available on all patients. Distal saphenous vein from the ankle or foot was the graft source in 16 procedures and basilic vein the source in one procedure. All operations were performed with headlight illumination, optical loupes, fine sutures, and microvascular instruments. There were no operative deaths or major complications. The mean follow-up period was 14 months. Of the 17 grafts, 16 remained patent by clinical and vascular lab criteria. The single occlusion occurred in an ulnar aneurysm bypass and was accompanied only by mild intolerance to cold.(ABSTRACT TRUNCATED AT 250 WORDS)

Carcinoid tumor of the gallbladder: laparoscopic resection and review of the literature

A 75-year-old woman with mild elevation of liver function test results was found to have an asymptomatic mass localized to the gallbladder by computed tomographic scan and ultrasonography. Endoscopic retrograde cholangiopancreatography revealed a fixed 2 x 4 cm filling defect in the gallbladder wall, consistent with a gallbladder neoplasm. The gallbladder and intramural neoplasm were excised successfully by use of uncomplicated laparoscopic cholecystectomy. Pathologic analysis revealed a carcinoid tumor of the gallbladder. All previously reported gallbladder carcinoid tumors in the Western literature are reviewed. Laparoscopic cholecystectomy has potential for application for the treatment of selected gallbladder neoplasms, with special preoperative assessment and intraoperative considerations being important.

Neurologic deficits following noncarotid vascular surgery

Neurologic events following noncarotid vascular surgery (NCVS) are considered unpredictable. To test this hypothesis, we reviewed our vascular registry for a 3-year period and identified all patients with new postoperative focal neurologic events (stroke, hemispheric transient ischemic attack [TIA]) within 2 weeks of a category I or II vascular procedure as defined by the American Board of Surgery, exclusive of carotid surgery and arterial trauma. Thirteen of 1,390 NCVS procedures (0.9%) in 13 patients were associated with focal neurologic events. There were 2 TIAs, 10 anterior circulation strokes, and 1 posterior circulation stroke. Twenty-seven percent of strokes were fatal. The neurologic deficit developed in the immediate postoperative period in 31%, more than 4 hours but less than 72 hours postoperatively in 54%, and within 3 to 14 days postoperatively in 15%. Patients with anterior circulation events (group A, n = 12) were compared for variables potentially influencing postoperative stroke with case controls who were selected using a table of random numbers (group B, n = 12). Controls were derived from a pool of all category I or II NCVS procedures recorded in our vascular registry sequentially during the same time period and who were without new neurologic deficits postoperatively. Using Fisher's exact test, comparisons between groups A and B revealed that new anterior circulation neurologic events in vascular surgical patients tended to be associated with intra-abdominal procedures (p less than 0.05), perioperative hypotension (p less than 0.05), and the presence of a greater than or equal to 50% internal carotid artery stenosis ipsilateral to the neurologic event (p less than 0.001). Such information may prove useful in the management of selected patients prior to arterial reconstruction and in operated NCVS patients with postoperative neurologic events.

A prospective audit of regional anaesthesia for hand surgery

A prospective audit has been carried out of 153 consecutive regional anaesthetics for hand surgery, using intravenous regional anaesthesia (IVRA), axillary block or multiple peripheral nerve blocks in the upper limb. Surgery was carried out successfully in 147 patients. Apart from two patients, who complained of paraesthesia after regional nerve blocks, there were no side-effects. A total of 13 patients said that they would have preferred a general anaesthetic. Regional anaesthesia was found to be suitable for use by members of the surgical staff, but success was only assured by meticulous attention to detail and by careful safety precautions. Regional anaesthesia should not be attempted by inexperienced, unsupervised hand surgeons.

Accuracy of lower extremity arterial duplex mapping

We performed lower extremity arterial duplex mapping from the aortic bifurcation to the ankle in 150 consecutive patients evaluated for aortic and lower extremity arterial reconstruction and compared lower extremity arterial duplex mapping in a blinded fashion to angiography. On the basis of history, physical examination, and four-cuff segmental Doppler pressures individual lower extremities were classified as normal, isolated aortoiliac disease, infrainguinal disease, and multilevel inflow and outflow disease. For vessels proximal to the tibial arteries, lower extremity arterial duplex mapping was analyzed for its ability to insonate individual arterial segments, detect a 50% or greater stenosis, and distinguish stenosis from occlusion. In the tibial arteries lower extremity arterial duplex mapping was evaluated for its ability to visualize tibial vessels and to predict interruption of tibial artery patency from origin to ankle. Lower extremity arterial duplex mapping visualized 99% of arterial segments proximal to the tibial vessels, with overall sensitivities for detecting a 50% or greater lesion ranging from 89% in the iliac vessels to 67% at the popliteal artery. Stenosis was successfully distinguished from occlusion in 98% of cases. In the tibial vessels lower extremity arterial duplex mapping was better at visualizing anterior tibial and posterior tibial artery segments (94% and 96%) than peroneal artery segments (83%), (p less than 0.001). Overall sensitivities for predicting interruption of tibial artery patency were 90% for the anterior tibial, 90% for the posterior tibial, and 82% for the peroneal. Clinical disease category did not influence in a major way the accuracy of lower extremity arterial duplex mapping in either above-knee or below-knee vessels.

Surgical management of severe acute lower extremity ischemia

Seventy-four patients (70 men [95%], 4 women [5%], mean age, 63 years) with severe, acute lower limb ischemia (acute clinical deterioration and absent pedal Doppler signals) caused by either arterial thrombosis (n = 68) or embolism (n = 6) underwent urgent surgical management consisting of operative revascularization with or without amputation in 67 patients (91%) and primary amputation alone in 7 patients (9%). Sixty-one patients (82%) had severely threatened limb viability, and 13 (18%) had major irreversible ischemic limb changes at presentation. Eighty-six percent of patients were initially anticoagulated with heparin. Seventy percent underwent preoperative angiography. Surgical revascularization included 42 inflow and 20 outflow arterial reconstructions and 9 thrombectomy or embolectomy procedures. Mean follow-up was 17 months (range, 0 to 64). Life-table primary patency at 36 months for arterial reconstructions was 81% for inflow and 78% for outflow procedures. Cumulative limb salvage was 70% at 1 month and 68% at 36 months. Patient survival was 85% at 1 month and 51% at 36 months. No death was directly attributable to complications related to limb reperfusion, and no patient required dialysis for myoglobinuria. We conclude that management of severe, acute lower limb ischemia with early amputation of nonviable limbs and heparinization, angiography, and prompt operative revascularization for threatened but viable extremities minimizes morbidity and mortality rates, while maximizing limb salvage. These results may be useful for comparison with comparable groups of patients treated with thrombolytic or endovascular modalities.

The incidence of perioperative myocardial infarction in general vascular surgery

In a 1-year period all patients undergoing general vascular surgery (491 patients, 534 procedures) underwent monitoring by creatine phosphokinase isoenzymes and electrocardiograms (ECG) to detect perioperative myocardial infarction. Only those patients with severe symptomatic coronary artery disease (31 patients, 5.8%) characterized by unstable angina pectoris, uncontrolled arrhythmia, or severe congestive heart failure had any testing for coronary artery disease beyond history, physical examination, and ECG. Only three patients (0.5%) had prophylactic coronary artery bypass performed before general vascular procedures. Twenty-one (3.9%) myocardial infarctions (five asymptomatic, detected by enzymes only, and 16 symptomatic, four of which were fatal) were associated with the 534 procedures (aorta 105, carotid 87, infrainguinal bypass 207, extraanatomic 51, other 84). Eight noncardiac perioperative deaths occurred. All operative deaths (12 of 534, 2.2%) including all four fatal myocardial infarctions occurred associated with surgery on an urgent or emergency basis (12 of 249 procedures, urgent/emergent operative mortality rate 4.8%). No operative deaths and no fatal myocardial infarctions associated with the 285 elective procedures occurred. Nine of the 17 nonfatal myocardial infarctions (53%) also occurred after urgent/emergent procedures. The rate of perioperative myocardial infarctions (eight of 285, 2.8%) after elective surgery in this patient series is no different from that reported by multiple recent authors advocating widespread screening for and prophylactic treatment of coronary artery disease before general vascular surgery. Our experience confirms the therapeutic approach that expensive and invasive coronary screening programs in patients to undergo vascular operations should be limited to carefully selected patients with severely symptomatic coronary disease.

Vascular contractions to serotonin are augmented by cooling

Human saphenous veins (HSV; n = 17) were obtained at surgery and assayed immediately. The veins were cut into rings, suspended in organ chambers and connected to force transducers for the recording of isometric tension. Tail arteries (RTA) from male Sprague-Dawley rats were similarly prepared. In quiescent rings, cooling from 37 to 24 degrees C had no significant effect. In the presence of alpha-adrenoceptor blockade, potassium chloride (KCl, 10-80 mM) caused concentration-dependent contractions that were inhibited slightly by cooling. Serotonin (5-HT, 10(-8)-10(-5) M) elicited concentration-dependent contractions in both the HSV and RTA with EC50's (-log concentration required to induce contractions 50% of maximal) of 6.31 +/- 0.03 and 6.55 +/- 0.06, respectively. These contractions were subject to blockade with the S2-selective 5-HT antagonist, ketanserin. When either HSVs or RTAs were contracted with 5-HT and cooled, a potent augmentation of the contractions ensued. The data indicate that, while acute moderate cooling does not significantly augment either resting tone or KCl-induced contractions of HSV or RTA, S2-receptor-mediated events are enhanced, yielding potent augmentations of the vascular response to the platelet-derived compound, serotonin. The relationship between temperature and serotonergic receptor responsiveness may be of clinical importance as a mechanism contributing to cold-induced vasospasm.

Limb salvage vs amputation for critical ischemia. The role of vascular surgery

Since 1980, 498 patients with 627 critically ischemic legs (rest pain, gangrene, ischemic ulcer, and ankle-brachial pressure index less than 0.40) were treated with revascularization regardless of operative risk or anticipated operative difficulty. Primary amputation was performed only when no graftable distal vessels were present (14 primary amputations [2.8%]) or in neurologically impaired, hopelessly nonambulatory patients. The mortality for revascularization was 2.3%, and the median hospital stay was 11 days. During follow-up, 41 limbs (7%) required amputation, 31 after failure of revascularization and 10 despite patent revascularizations. Renal failure had an adverse influence on limb salvage (67%) because of a significantly increased requirement for amputation despite patent revascularizations. We conclude aggressive limb revascularization in patients with critical lower-extremity ischemia results in low operative morbidity and mortality and excellent long-term limb salvage. Patients with critical leg ischemia and renal failure are at higher risk for limb loss than patients without renal failure.

Duplex ultrasound criteria for diagnosis of splanchnic artery stenosis or occlusion

Mesenteric artery duplex scanning appears promising for detection of splanchnic artery stenosis or occlusion or both in patients with symptoms suggestive of chronic intestinal ischemia. However, no specific duplex criteria have been developed for detection of mesenteric artery stenosis. We obtained mesenteric artery duplex scans and infradiaphragmatic lateral aortograms in 34 patients to determine duplex criteria for mesenteric stenosis. Seventy percent or greater angiographic stenosis was present in 10 superior mesenteric arteries and 16 celiac arteries. Duplex scans were reviewed to determine if celiac artery and superior mesenteric artery ratios of peak systolic velocities and end-diastolic velocities to peak aortic systolic velocity, as well as celiac artery and superior mesenteric artery peak systolic velocities and end-diastolic velocities alone, could predict a greater than or equal to 70% angiographic stenosis or occlusion or both. The results obtained by use of receiver operator curves indicated peak systolic velocity alone was an accurate predictor of splanchnic artery stenosis. Specifically, a peak systolic velocity greater than or equal to 275 cm/sec in the superior mesenteric artery and greater than or equal to 200 cm/sec in the celiac artery or no flow signal (superior mesenteric artery and celiac artery) predicted a 70% to 100% stenosis with sensitivity, specificity, and positive predictive values of 89%, 92%, and 80% for the superior mesenteric artery. Similar values for the celiac artery were 75%, 89%, and 85%, respectively. End-diastolic velocities or calculated velocity ratios conveyed no additional accuracy in predicting splanchnic artery stenosis.

A comparative investigation of re-epithelialisation of split skin graft donor areas after application of hydrocolloid and alginate dressings

The performances of hydrocolloid and alginate dressing materials have been compared in a study of 65 split skin graft donor areas. The donor areas were randomised between the two dressing materials. The rates of epithelialisation, the discomfort experienced by the patients and the convenience of the dressings in clinical use were compared. At the time of the first dressing change 87% of the donor areas dressed with the hydrocolloid and 86% of the donor areas dressed with the alginate were found to be more than 90% healed. The mean time from operation to the observation of complete healing was 10.0 days for the donor areas dressed with the hydrocolloid and 15.5 days for the donor areas dressed with the alginate: this difference was found to be statistically significant. The discomfort experienced by the two groups of patients was comparable. The rapid healing associated with the hydrocolloid dressing was thought to be of greatest benefit to inpatients; alginate dressings were thought to be more suitable for outpatients, as they proved to be simpler to use.

Dietary eicosapentaenoic acid and docosahexaenoic acid from fish oil. Their incorporation into advanced human atherosclerotic plaques

The incorporation of fatty acids from dietary fish oil was measured in obstructive atherosclerotic plaques removed from 11 patients fed fish oil, rich in omega-3 fatty acids, for 6-120 days before a planned arterial endarterectomy. The fatty acids of plasma and atheroma were analyzed with special reference to docosahexaenoic acid (DHA, 22:6) and eicosapentaenoic acid (EPA, 20:5), the principal omega-3 fatty acids of fish oil. The omega-3 fatty acid content increased greatly in plasma from 0.9% of fatty acids to 14.8% in cholesteryl esters, from 3.8% to 22.1% in phospholipids, and from 1.3% to 21.9% in triglycerides. The omega-3 fatty acid content of the atherosclerotic plaques was also greater when compared with that of plaques removed from 18 non-fish oil-fed controls. The omega-3 fatty acid in cholesteryl esters of the plaques was 4.9% in the experimental group versus 1.4% in control plaque, in phospholipids it was 8.8% versus 1.8%, and in triglycerides it was 4.7% versus 0.7% (p less than 0.001 for each lipid class). The two major omega-3 fatty acids (DHA and EPA) behaved differently. Compared with their respective plasma levels, relatively more DHA than EPA was deposited into the plaques. Whereas the increase of omega-3 fatty acids in plasma reached a plateau 3 weeks after initiation of fish oil feeding, a linear increase in plaque omega-3 fatty acids continued with time. As a result of the changes in fatty acid composition, the lipid classes of both plasma and plaque had a higher unsaturation index in the fish oil-fed group.(ABSTRACT TRUNCATED AT 250 WORDS)

Fifteen-year results of ambulatory compression therapy for chronic venous ulcers

A nonoperative approach to venous stasis ulceration of the lower extremity, consisting of initial bedrest, ulcer cleansing, dressing changes, and ambulatory elastic compression stocking therapy, has been maintained for over 15 years. All patients had class III, severe chronic venous insufficiency. One hundred five of 113 patients (93%) experienced complete ulcer healing in a mean of 5.3 months. One hundred two patients were compliant with elastic compression stockings, and 11 patients were noncompliant. Complete ulcer healing occurred in 99 of 102 patients (97%) who were compliant versus six of 11 patients (55%) who were noncompliant (p less than 0.0001). The influence of noncompliance, previous venous ulceration, previous venous surgery, previous known deep venous thrombosis, peripheral arterial insufficiency (ankle brachial systolic blood pressure index less than or equal to 0.60), pretreatment ulcer duration, ulcer size, age, sex, diabetes, smoking, and photoplethysmography venous refill time on ulcer healing was determined by logistic regression analysis. Only noncompliance with elastic compression stockings (p less than 0.0001) and a pretreatment ulcer duration of more than 9 months (p = 0.02) significantly decreased initial ulcer healing. Posthealing follow-up was available in 73 patients for a mean of 30 months. Fifty-eight patients (79%) continued to be compliant with stockings; 15 patients were noncompliant. Total ulcer recurrence in patients who were compliant was 16%. Five-year lifetable recurrence was 29%. All patients who were noncompliant had recurrent ulceration by 36 months. Previous ulceration, previous venous surgery, and peripheral arterial insufficiency had no effect on ulcer recurrence (p greater than 0.05).

Cooling augments alpha 2-adrenoceptor-mediated contractions in rat tail artery

Experiments were performed to assess the effects of acute moderate cooling on postjunctional alpha 1- and alpha 2-adrenoceptors in isolated rings of tail arteries from male Sprague-Dawley rats. Rings were contracted with norepinephrine (NE; 10(-9) to 10(-4) M) alone or in the presence of prazosin (Pz; 3 x 10(-7) M) or rauwolscine (Rw; 10(-7) M). NE concentration-response curves were inhibited by alpha 1-blockade (Pz) but not significantly affected by alpha 2-blockade (Rw). In all rings, cooling caused an increase in the slope of the dose-response curve and a significant increase in the concentration of agonist required to evoke contractions, as assessed by that concentration of NE required to evoke a contraction equal to 10% of maximal (EC10). Cooling inhibited contractions evoked by the selective alpha 1-adrenergic agonist phenylephrine (PE) as assessed by EC10 but had no significant effect on the weak contractions elicited by the selective alpha 2-adrenergic agonist B-HT 920. Prior elevation of tone with either KCl or prostaglandin F2 alpha enhanced alpha 2-mediated contractions. These contractions were augmented by cooling, whereas those caused by either KCl or prostaglandin F2 alpha alone were not significantly affected. Our results suggest that alpha 2-adrenoceptor-mediated responses in this blood vessel are dependent on the level of preexisting tone and are potentiated by cooling.

Symptoms of Raynaud's syndrome in patients with fibromyalgia. A study utilizing the Nielsen test, digital photoplethysmography, and measurements of platelet alpha 2-adrenergic receptors

Twenty-nine female patients with fibromyalgia were questioned about symptoms of cold intolerance and Raynaud's syndrome; objective documentation of cold-induced vasospasm was obtained by a Nielsen test. Twelve patients (41%) had abnormal Nielsen test results, and 11 patients (38%) had elevated levels of platelet alpha 2-adrenergic receptors. There was a positive correlation between the percentage of change in finger systolic pressure on cooling (Nielsen test) and the number of alpha 2-adrenergic receptors. There was poor correlation between Raynaud's syndrome symptoms and an abnormal Nielsen test result. Digital photoplethysmography showed a normal waveform in 2 of 3 patients. We hypothesize that a subgroup of patients with fibromyalgia syndrome have an up-regulation of alpha 2-adrenergic receptors as a cause of their exaggerated reaction to cold.

Clinical and anatomic considerations for surgery in femoropopliteal disease and the results of surgery

From 1980 to 1988 we performed 288 femoropopliteal bypass operations in 231 patients at the Oregon Health Sciences University. The indication for the procedure was claudication in 31% and the relief of limb-threatening ischemia in 64%. Operative mortality occurred after four of these operations (1.4%), including three deaths from myocardial infarction and one death from stroke. The femoropopliteal bypass patients were divided into groups for patency analysis, including those undergoing bypass surgery with a good quality greater saphenous vein versus alternate bypass conduits and patients undergoing primary limb bypass versus those undergoing repeat bypass after prior bypass failure. Our overall primary graft patency for all femoropopliteal grafts was 79% at 5 years. Patients undergoing bypass with a good quality greater saphenous vein had primary graft patency of 85% at 5 years. Patients undergoing bypass using a conduit other than greater saphenous vein had a 5-year patency of 73%. Patients undergoing repeat bypass after a prior failed bypass had a 5-year patency of 57%.

Simultaneous operative repair of multilevel lower extremity occlusive disease

Sixty-two patients (39 men (63%), 23 women (27%), mean age 68 years) with multilevel lower extremity arterial occlusive disease underwent simultaneous inflow and outflow operative arterial repair consisting of aortofemoral bypass in 22 (35%), axillofemoral bypass in 17 (28%), femorofemoral bypass in 15 (24%), iliac endarterectomy in 7 (11%), and unilateral aortoiliac bypass in 1 (2%), combined with 69 outflow procedures (unilateral in 55 patients, 89%), including above-knee femoropopliteal in 12 (17%), below-knee femoropopliteal in 35 (51%), femoroinfrapopliteal in 20 (29%), popliteal tibial in 1 (1%), and femoropedal bypass in 1 (1%). Multiple criteria were used to identify patients with multilevel disease likely to benefit from multilevel procedures. The operations were performed by two operating teams in a median time of 240 minutes. Prosthetic grafts were used for eight (13%) distal bypasses, the remainder were autogenous vein. There was one operative death (1.8%). The mortality rate, morbidity rate, and operative time were not significantly different from a group of patients who underwent concurrent, isolated inflow operations (aortofemoral, axillobifemoral, femorofemoral bypass or iliac endarterectomy). Mean follow-up was 14.9 months (range, 0 to 120). The life-table primary patency for the inflow procedures was 92.6% at 24 months, the outflow was 94.9% at 24 months. Cumulative limb salvage was 90.9% at 48-month follow-up. All patients with claudication were relieved of their symptoms. We conclude that complete correction of multilevel disease can be accomplished with operative time, morbidity rate, and patency equal to that of single level repair. Multilevel procedures provide complete relief of symptoms in a higher percentage of patients than has been reported after single level repair.

The association of elevated plasma homocyst(e)ine with progression of symptomatic peripheral arterial disease

Plasma homocyst(e)ine (the sum of free and bound homocysteine, homocystine, and the mixed disulfide homocysteine-cysteine, expressed as homocysteine) levels were determined by high performance liquid chromatography in 214 patients with symptomatic (claudication, rest pain, gangrene, amputation) lower extremity arterial occlusive disease and/or symptomatic (stroke, cerebral transient ischemic attacks) cerebral vascular disease and in 103 control persons. Mean plasma homocyst(e)ine was significantly higher in patients than in controls (14.37 +/- 6.89 nmol/ml vs 10.10 +/- 2.16, p less than 0.05). Thirty-nine percent of patients (83 of 214) had plasma homocyst(e)ine values greater than control mean + 2 standard deviations. Plasma homocyst(e)ine values were contrasted to age, male sex, diabetes, hypertension, smoking, renal failure, and plasma cholesterol. No difference was found in the incidence and/or level of any of these risk factors when patients with normal plasma homocyst(e)ine were compared to those with elevated plasma homocyst(e)ine, both by univariate and multivariate analysis. Patients with elevated plasma homocyst(e)ine were more likely to demonstrate clinical progression of lower extremity disease and of coronary artery disease, but not of cerebral vascular disease than were patients with normal plasma homocyst(e)ine, and the rate of progression was more rapid (p = 0.002). Progression of lower extremity disease as assessed in the vascular laboratory was also more common in patients with elevated plasma homocyst(e)ine (p = 0.01). We conclude that elevated plasma homocyst(e)ine is an independent risk factor for symptomatic lower extremity disease or cerebral vascular disease or both. Symptomatic patients with lower extremity disease and with elevated plasma homocyst(e)ine also appear to have more rapid progression of disease.

The influence of elastic compression stockings on deep venous hemodynamics

To determine the effect of elastic compression stockings on deep venous hemodynamics we measured ambulatory venous pressure, venous refill time, maximum venous pressure with exercise, amplitude of venous pressure excursion, and duplex-derived common femoral and popliteal vein diameter and peak flow velocities with and without stockings in 10 healthy subjects and 16 patients with chronic deep venous insufficiency. The effects of below-knee and above-knee 30 to 40 torr and 40 to 50 torr gradient stockings were studied. Despite documentation of substantial stocking compressive effects by skin pressure measurements, neither below-knee or above-knee elastic compression stockings significantly improved ambulatory venous pressure, venous refill time, maximum venous pressure with exercise, or the amplitude of venous pressure excursion in healthy patients or in patients with deep venous insufficiency (p greater than 0.05). In patients with deep venous insufficiency stockings modestly increased popliteal vein diameter and flow velocity in the upright resting position (p less than 0.02). After tiptoe exercise without stockings deep venous peak flow velocity increased in healthy patients and in patients with deep venous insufficiency by a mean of 103% in the popliteal vein and 46% in the common femoral vein (p less than 0.01). With the application of elastic compression stockings only modest augmentation of deep venous flow velocity occurred in both groups above that seen in the bare leg after exercise. Thus elastic compression stockings did not improve deep venous hemodynamic measurements in patients with deep venous insufficiency. The beneficial effects of stockings in the treatment of deep venous insufficiency must relate to effects other than changes in deep venous hemodynamics.

The importance of routine surveillance of distal bypass grafts with duplex scanning: a study of 379 reversed vein grafts

To assess the utility of routine duplex surveillance, 379 infrainguinal reversed vein grafts performed at two independent teaching hospitals were prospectively entered into a surveillance protocol from March 1986 through August 1989. An average of 3.2 postoperative duplex graft flow velocity (GFV) measurements per graft was obtained during a mean follow-up interval of 21 1/2 months. Only 2.1% of 280 grafts with GFV measurements greater than 45 cm/sec failed within 6 months of a normal surveillance examination. GFV measurements less than 45 cm/sec in 99 grafts led to arteriography in 75 grafts, identifying 50 stenotic lesions in 48 bypasses (12.6% of series). Inflow lesions were present in 5%, outflow stenoses in 2%, and intrinsic graft stenoses in only 6% of bypasses. Only 29% of grafts identified as failing by duplex scan were associated with a reduction in ankle-brachial index of greater than 0.15. Secondary reconstructions were performed in 48 grafts based on detection of a reduced GFV measurement; all such reconstructions are patent after a mean follow-up of 5 months. Duplex surveillance is more reliable in identification of failing vein grafts than is determination of ankle-brachial index.

Clinical results of axillobifemoral bypass using externally supported polytetrafluoroethylene

Seventy-six axillobifemoral grafts with externally supported polytetrafluoroethylene prostheses were performed since 1983. The indications for operation were absolute (aortic sepsis) in 20 (26%) patients and relative (excessive operative risk or technical difficulty) in 56 (74%) patients. The life-table primary patency for these operations at 4 years follow-up (mean follow-up, 2 years, 4 months) was 85%. We conclude that the patency results achieved in this patient series are sufficiently satisfactory to warrant use of axillobifemoral grafts in an expanded number of patients with high operative risk and need for bypass of aortoiliac occlusive disease.

The effects of cooling on human saphenous vein reactivity to adrenergic agonists

Human saphenous veins were obtained at surgery and assayed immediately (n = 10). The veins were cut into rings, suspended in organ chambers, and connected to force transducers for the recording of isometric tension. One ring served as control whereas others were treated with the alpha 1-adrenoceptor antagonist prazosin (3 X 10(-7) mol/L), or the alpha 2-adrenoceptor antagonist rauwolscine (10(-7) mol/L). In quiescent rings cooling from 37 degrees C to 24 degrees C had no significant effect. Norepinephrine (10(-8)-10(-5) mol/L) caused concentration-dependent contractions with an EC20 (-log concentration of norepinephrine required to induce contractions 20% of maximal) = 6.97 +/- 0.10. The contractions were inhibited by prazosin (EC20 = 5.89 +/- 0.17, p less than 0.001) and rauwolscine (ED20 = 5.78 +/- 0.11, p less than 0.001). In control rings cooling potentiated contractions evoked at concentrations of norepinephrine below 10(-6) mol/L and inhibited those at higher concentrations. In rings treated with alpha-antagonists cooling depressed the maximal contractile responses. Contractions to the alpha 1-agonist, phenylephrine (10(-7)-10(-4) mol/L), were inhibited by cooling, whereas those to the alpha 2-specific agonist B-HT 920 (10(-7)-10(-4) mol/L) showed a pattern similar to that seen with norepinephrine. The data indicate that the human saphenous vein possesses both alpha 1- and alpha 2-adrenoceptors postjunctionally, and that both contribute to contractile responses. Cold augments saphenous vein reactivity to norepinephrine by an apparent increase in the responsiveness of alpha 2-adrenoceptors to agonists. The relationship between temperature and adrenoceptor responsiveness may be of pivotal importance in defining the mechanism of cold-induced vasospasm.

Vascular surgery residency training curriculum

The decision to establish a vascular surgery residency confers significant obligations on the institution, the program director, and the faculty. An optimal vascular residency training program must be carefully structured both organizationally and educationally. The Residency Review Committee for Surgery has developed a generally complete and well-reasoned group of requirements for the vascular residency. Nonetheless the program director has considerable latitude in shaping the residency to accommodate these requirements. Our institutional approach to the structure and content of vascular surgery residency training is presented herein.

Surgical treatment of distal ulnar artery aneurysm

In the past 7 years, we have encountered six patients with finger ischemia as a result of digital artery occlusion associated with seven distal ulnar artery aneurysms. Our experience with the management of these patients forms the basis of this report. All patients were men, with a mean age of 29 years, and all experienced repetitive trauma to the involved upper extremity. Each patient presented with the acute onset of cool and painful digits, with no previous history of cold sensitivity or Raynaud's syndrome. None of the patients had any serologic or clinical evidence of autoimmune disease. Angiography revealed occlusion of the ulnar artery on the affected side in two patients and patent ulnar artery aneurysms in the remaining five patients. There was occlusion of multiple common and proper digital arteries in all patients. One patient with bilateral ulnar artery aneurysms underwent operative repair consisting of aneurysm excision and replacement with autogenous vein grafts from the lower extremity. All patients have improved symptoms, and the grafts remained patent over a mean follow-up of 24 months (range: 13 to 57 months). Based on these results, we recommend that excision and grafting be considered for patients with symptomatic patent ulnar artery aneurysms. Selected patients with thrombosed aneurysms with ongoing digital ischemia may also benefit from surgical intervention.

Improving survival and limb salvage in patients with aortic graft infection

A 15-year experience with 38 aortic graft infections, including 15 patients with graft enteric fistulas, is reviewed in order to analyze modern-day surgical results utilizing extra-anatomic bypass and aortic graft excision. Perioperative mortality was 14% during the most recent 7-year interval, which was a notable improvement compared with the earlier time interval (p = 0.06). Extended follow-up of the perioperative survivors demonstrated a 77% cumulative 5-year survival and a 76% cumulative 5-year limb salvage rate. Subsequent axillofemoral graft infection occurred in 22% of survivors and resulted in a significantly higher amputation rate compared with those patients with no axillofemoral graft infection (p less than 0.001). The results suggest good perioperative and long-term survival in patients with aortic graft infection, with excellent limb salvage if subsequent axillofemoral graft infection can be avoided.

Can duplex scanning replace arteriography for lower extremity arterial disease?

This preliminary study was undertaken to determine if surgeons would choose different intervention for lower extremity occlusive disease when given basic clinical information and data from either a duplex scan or arteriogram. Information on degree of stenosis from duplex scans and arteriograms of 29 patients was indicated on an anatomical line drawing along with the ankle blood pressures and a brief clinical description. Based on these data sheets, six vascular surgeons chose a clinical plan in a blinded fashion for each patient. Each plan was placed into one of eight possible categories for comparison using the kappa statistic. Intraobserver agreement between surgeons' decisions based on duplex scanning versus those based on arteriography was very good (mean kappa .70 with exact agreement in 76%). Interobserver agreement between different surgeons' decisions based on the same studies was significantly less (mean kappa 0.56, p less than .05). Significant disparity in clinical approach occurred in 43% of the patients with nearly identical duplex scan and arteriogram reports, suggesting that much of the discrepancy lies in the clinical decision-making process. Clinical decisions made using duplex scans are very similar to those made using arteriograms. This technique can limit the need for arteriography in assessing patients with lower extremity arterial occlusion disease.

Present status of reversed vein bypass grafting: five-year results of a modern series

From January 1980 through December 1988, 564 limbs in 434 patients were treated for infrainguinal arterial ischemia. Of these, 516 limbs in 387 patients underwent reversed vein bypass grafting. The remainder were treated by primary amputation (11 limbs, 1.9%) or by prosthetic bypass (37 limbs, 6.4%). The indications for operation were limb salvage in 80% of limbs and claudication in 20%. Adequate ipsilateral greater saphenous vein was available for 285 (55%) grafts, with reversed vein bypass achieved in the other 231 operations by use of distal graft origins (151 grafts), use of alternate vein sources (120 grafts), and splicing of venous segments (81 grafts). Seventy-six grafts (15%) were to the above-knee popliteal artery, 199 grafts (37%) were to the below-knee popliteal artery, and 241 grafts (47%) were to infrapopliteal arteries, 26 of which (11%) were to inframalleolar arteries. The primary and secondary patencies for all grafts at 5 years were 75% and 81%, respectively. Grafts to infrapopliteal arteries had significantly worse primary patency (69%) at 5 years than did grafts to the popliteal artery (77%, above knee; 80%, below knee) and grafts formed of adequate ipsilateral greater saphenous vein had significantly better primary patency (80%) than did grafts performed when this conduit was not available (68%). Secondary patency of all graft categories ranged from 76% to 85%, and there were no significant differences regardless of site of distal anastomosis, source of venous conduit, or site of graft origins. We prefer the use of reversed vein bypass grafting for lower extremity revascularization both because of the excellent patency results and because the technique can be applied to the larger number of patients in our practice who lack intact ipsilateral greater saphenous vein, in contrast to in situ vein bypass procedures.

Late complications after femoral artery catheterization in children less than five years of age

Fifty-eight children who underwent diagnostic femoral artery catheterization before 5 years of age, from 5 to 14 years before the study, were randomly selected from approximately 300 surviving patients undergoing diagnostic femoral artery catheterization at our institution during the interval. Each patient underwent vascular laboratory segmental pressure and waveform examination and arterial duplex scanning, as well as lower extremity bone length radiographs, which were considered positive if the catheterized leg was greater than or equal to 1.5 cm shorter than the opposite leg. Thirteen children who had only venous catheterization served as controls. No arterial abnormalities were present in the control patients (mean ankle/brachial index, 1.01). Arterial occlusion was present in both limbs of five patients who had bilateral diagnostic femoral artery catheterization and in 14 limbs of 51 patients who had unilateral diagnostic femoral artery catheterization. Thus arterial occlusion was present in 33% of patients (19 of 58) and in 37% of limbs (24 of 65). The mean ankle/brachial index in the catheterized limbs was 0.79. Leg growth retardation was present in four limbs (8%) of 51 children undergoing unilateral diagnostic femoral artery catheterization and in one (8%) control patient. The inverse relationship between ankle/brachial index and leg growth retardation was significant (R = 0.47, p less than 0.0005). Only one patient had symptoms of arterial occlusion (claudication), and one patient had symptoms of leg growth retardation (gait disturbance). We conclude that arterial occlusion is common after diagnostic femoral artery catheterization in children less than 5 years of age, but that excellent collateral supply prevents leg growth retardation and/or symptomatic arterial insufficiency in most children.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of failed lower extremity bypass grafts with new autogenous vein bypass grafting

During the last 9 years we performed 111 bypass procedures for lower extremity ischemia, which occurred after failed infrainguinal bypass grafting. An all autogenous reversed vein bypass was achieved in 103 of 111 operations (93%). Five-year primary and secondary patency of bypasses placed as treatment for one or more failed prior bypass(es) was 57% and 71%, respectively, as compared to 80% and 83%, respectively, for 5-year primary and secondary patency of simultaneously placed first time leg bypasses. Five-year limb salvage for bypass procedures performed as treatment for failed bypass was 90%, which was identical to that achieved for first time bypasses.

Epithelioid hemangioendothelioma of the external iliac vein: a primary vascular tumor presenting as traumatic venous obstruction

A 32-year-old man employed as a laborer presented with the signs and symptoms of iliofemoral venous obstruction of 1 months' duration. Results of initial phlebography from the ankle to the femoral area were normal. No iliac vein anatomy was seen. This led to a group of tests directed toward neuromuscular function, which were unrewarding. On referral to our institution a noninvasive venous vascular laboratory examination was performed, which clearly indicated iliac vein obstruction/stenosis, with a normally patent distal venous system. Subsequent repeat phlebography, including direct femoral vein injection, visualized a mass lesion partially occluding the iliac vein. This lesion was treated with primary excision and segmental venous replacement with an interposition graft of autogeneous internal jugular vein. The excised lesion proved to be an epithelioid hemangioendothelioma of the iliac vein.

Role of revascularization to treat chronic nonhealing fractures in ischemic limbs

The contribution of chronic limb ischemia to long-term nonunion of a lower extremity fracture was suggested in a single published case report from our group 13 years ago. We have since encountered three additional patients with nonunited lower extremity fractures occurring in limbs with arterial ischemia. In each of these four patients limb revascularization was undertaken in an effort to stimulate healing of the fracture. These patients had chronic (mean 6 months) nonunion of tibial (three) or femur (one) fractures associated with severe lower extremity ischemia (ankle/brachial index m = 0.33; range 0.24 to 0.5). All patients had histories of chronic lower extremity ischemia before the fracture (ischemic rest pain, 2; claudication, 2). All patients underwent angiography followed by lower extremity revascularization. Restoration of normal arterial supply to the fracture site was followed by healing of the fracture in all patients. To our knowledge, this represents the first reported series of patients undergoing elective limb revascularization to stimulate healing of the fracture. Widespread appreciation of this relationship by orthopedic surgeons may be of considerable clinical importance.