Lower limb ischaemia in the octogenarian: is limb salvage surgery worthwhile?

Vascular surgeons are being asked to manage vascular disease in an increasingly elderly population, and advanced age may be considered a relative contraindication to limb salvage surgery with an amputation seeming the preferred option. We present a review of 50 patients over the age of 80 years, presenting with ischaemic rest pain, ulceration or gangrene of the lower extremity. Six patients were treated conservatively, four of whom died during the same admission. Only two patients proved suitable for transluminal angioplasty as the sole curative procedure. Twelve patients (24%) underwent primary amputation with a perioperative mortality of 3/12 (25%). Five patients (10%) had an iliac bypass procedure, and 25 patients (50%) were considered suitable for infrainguinal bypass. Of the latter group 14 had femoropopliteal bypasses, and 11 had femorodistal bypasses with an overall perioperative mortality of 3/25 (12%). Mortality at 6 months was high (33%) and was similar in both the grafted and amputation groups. Patients having reconstruction fared well in terms of independent mobility, use of long-term care, and length of hospital stay. Patients over 80 years of age with critical ischaemia should not be denied the opportunity of vascular reconstruction.     

Tibial and peroneal bypass in severe occlusive disease of the lower extremities

Symptomatic arteriosclerotic occlusive disease involving the femoral and proximal popliteal arteries is currently best treated by reversed autogenous saphenous vein bypass graft. Severe occlusive disease frequently includes the popliteal and/or origin of the trifurcation vessels with reconstitution of one or more of the vessels in the lower leg. We have used distal bypass 97 times in 90 patients during the past decade. There was only one postoperative death in the series in spite of the advanced age and concurrent disease in the majority of the patients. Our indications for operation continue to be relief of pain or salvage of an extremity. We rely on high quality preoperative angiograms for selection of vessels to receive the bypass. The posterior tibial artery was used in 63 of the cases, while the anterior tibial and peroneal were used in 24 and 10 cases, respectively. There were 11 immediate inhospital failures in this series of 97 cases requiring amputation in five. Three additional patients had amputations during the ensuing several months. Of the 85 grafts functioning at the time of discharge from the hospital, 16 or (18.8%) failed during the first years. Grafts that remained patent for one year have a high incidence of long term patency which is in keeping with other reported series.     

The use of physiotherapy and antibacterial preparations in urogenital infections

335 patients with obliterative diseases of arteries of the low extremities were examined. Results of motor rehabilitation depend on the severity of post-amputation defect of the extremity and functional condition of the stump. The lower is the level of the amputation the higher is the effectiveness of the rehabilitational measures. Ischemia of femoral stump springs up rarely but its course is mare severe than ischemia of the stump of the shin, which is confirmed by the data of clinical examination, investigation of biochemical parameters of the blood and mortality rate. For prophylaxis of ischemia of the stump it is suggested simultaneously with the amputation of the extremity to perform reconstructive procedures on the arteries, aimed at restoration of blood flow through the profound femoral artery. This policy provides the possibility to form a long functional stump of the extremity and to improve results of motor rehabilitation.     

Supracondylar femoral fractures in the frail elderly. Fractures in need of treatment

The investigators of this study reviewed 112 consecutive frail elderly patients with supracondylar femoral fractures to evaluate primarily functional outcomes to optimize initial treatment of these challenging patients. A high 1-year mortality rate (22%) and significant decrease in function and quality of life occurred in frail elderly patients who sustained supracondylar femoral fractures. No statistical relationship could be found among preinjury function, age, cognitive function, type of fracture, treatment, and overall results. Nine percent of patients required late above-knee amputation in the involved extremity because of displacement of the fracture or infection or both. Optimal treatment for this type of patient remains elusive. Primary above-knee amputation may be the preferred treatment in patients who are this severely affected.     

Carotid and lower extremity arterial disease in patients with renal artery atherosclerosis

BACKGROUND: Atherosclerotic lesions of the carotid and lower extremity arteries may be associated with renal artery stenosis and influence the management of patients with renal artery disease. OBJECTIVE: To document the prevalence and clinical features of carotid and lower extremity arterial disease in patients with renal artery atherosclerosis. METHODS: An analysis of baseline data on 149 patients enrolled in a prospective natural history study of atherosclerotic renal artery stenosis. Patients with at least 1 abnormal renal artery by duplex scanning were eligible. Carotid artery disease was evaluated by duplex scanning, and ankle/brachial indices were used to assess the lower extremity arteries. Disease at each of the 3 arterial sites was classified as mild, moderate, or severe based on the extent of involvement on both sides. Serum urea nitrogen, creatinine, and lipid levels were also measured. RESULTS: Severe renal, carotid, or lower extremity arterial disease was present in 44%, 19%, and 21% of the patients, respectively. There was a trend for patients with increasing degrees of renal artery disease to have increasing degrees of carotid and lower extremity arterial disease. The prevalence of severe carotid artery disease increased from 7% in the mild renal artery group to 28% in the severe renal artery group. Clinical factors that were most predictive of severe disease were elevated apolipoprotein B levels for the renal arteries, high serum urea nitrogen or creatinine levels for the carotid arteries, and smoking for the lower extremity arteries. CONCLUSIONS: There was a strong association between severe renal artery atherosclerosis and severe carotid artery disease. Patients with renal artery disease also had a high prevalence of lower extremity arterial disease. In this patient population, screening for lower extremity arterial disease can be reserved for those with signs or symptoms of peripheral ischemia. Noninvasive carotid screening is justified in patients with renal artery disease to detect asymptomatic lesions that require either immediate surgical treatment or serial follow-up for disease progression.     

Is intermittent pulsatile pressure a valuable adjunct in healing the complicated diabetic wound?

Diabetic neuropathic ulceration and subsequent lower extremity amputation are a significant cause of chronic disability. High-risk diabetic patients with infected foot wounds, poor lower extremity blood flow, and inadequately controlled blood glucose require prompt action by clinicians in order to successfully avoid more severe sequelae. Dysvascular patients who are poor candidates for arterial bypass surgery may benefit from adjunctive treatment with a pneumatic pedal compression device. The authors discuss the rationale behind this unique treatment modality and present a case report illustrating a successful outcome in a high-risk diabetic patient.     

Usefulness of transcutaneous oximetry in vascular surgery

The assessment is presented of the value of transcutaneous oximetry in vascular surgery and in choosing the level of ischaemic limb amputation. Transcutaneous measurements of oxygen pressure (tcp02) were performed in 172 patients operated on for chronic ischaemia of the lower limbs before and three weeks after the operation. The studied subjects had the following operations done: bifurcated or unilateral aortofemoral bypass, femoropopliteal bypass, restoration of patency of the iliac and femoral arteries, lumbar sympathectomy, lower limb amputation. The studies were carried out using Hellige SM 361 oxymonitor and a similar Polish device. For oximetric measurements superficial skin sensor (Clark's polarographic electrode) was used, which was applied into the dorsum of the foot and medial crural surface. Transcutaneous oximetry seems to be a useful method for the assessment of the results of operations restoring blood flow in lower limb arteries. It makes possible to evaluate the results of lumbar sympathectomy. Transcutaneous measurements of oxygen pressure are also a useful method for the assessment of results of amputation of chronically ischaemic lower limb.     

Pelvic fracture with shock-inducing retroperitoneal bleeding and concomitant lower extremity ischemia syndrome: discussion of management exemplified by a case report

BACKGROUND: Initial treatment of severe pelvic fracture consists of appropriate resuscitation and early pelvic reposition and stabilization. Concomitant retroperitoneal arterial bleeding in a hemodynamically unstable patient in combination with lower extremity ischemia make early management decisions very difficult and the mortality rate of this entity of injuries is extremely high. CASE REPORT: We report on a successful treatment of a 36 year old skier, referred in hemorrhagic shock, who had sustained a severely displaced both column fracture of the right acetabulum, an unstable pelvic ring injury on the left and a retroperitoneal bladder rupture. He developed complete ischemia of the right lower extremity. Angiography revealed an obliteration without extravasation of the external iliac artery and allowed treatment of a right superior gluteal artery disruption by embolization. The right lower extremity ischemia was revascularized with a subcutaneous femoro-femoral bypass graft. Delayed internal fixation of the right acetabulum and exploration of the iliac vasculature was done through an ilio-inguinal approach. Simultaneously, the cross-over bypass could be removed. After 18 months, the patient recovered without any ischemic symptoms, but continues with a mixed sciatic nerve lesion. DISCUSSION AND CONCLUSIONS: The combination of severe retroperitoneal arterial bleeding and total ischemia of the lower extremity requires immediate surgical therapy. Direct exploration of the retroperitoneum, however, can be fatal and should be avoided if the iliac vessels are angiographically intact or if a hemorrhage is controllable by an embolization procedure. Extraanatomic temporary revascularization of the lower extremity should be envisaged when a lower leg ischemia due to obliteration or compression of major intrapelvic vessels cannot be directly and immediately treated.     

Mechanical thrombectomy: results of early experience

PURPOSE: To evaluate the clinical application of a mechanical thrombectomy device in occluded lower extremity arteries and bypass grafts. MATERIALS AND METHODS: A mechanical thrombectomy device was used in five patients with acutely occluded lower extremity bypass grafts (n = 2) or superficial femoral arteries (n = 3). RESULTS: The thrombus was completely removed in three cases (two bypass grafts and one native superficial femoral artery). In two of the patients with occlusions in the native superficial femoral artery, the thrombus was partially removed. In these two patients, the aspirate demonstrated a more fibrous thrombus that was not easily fragmented. In one of these two patients, the coagulum was thought to be embolic from the heart. CONCLUSION: The thrombectomy device works well in recent thromboses, particularly in polytetrafluoroethylene grafts in which organization does not occur. Its efficacy in chronically occluded vessels is not certain.     

Spatial memory deficits following stimulation of hippocampal 5-HT1B receptors in the rat

The authors review the principles of reconstructive surgery for lower limb salvage after severe lower limb trauma to determine factors that have been used as decision-making criteria for limb salvage or amputation in severe lower extremity injuries and the methods of reconstruction and their outcome. The use of scoring systems and their value in acute decision making (primary amputation or limb salvage) are described. Soft-tissue reconstructive techniques, with emphasis on the use of flaps and the importance of selecting the best technique and time for the reconstruction are reviewed. Skeletal reconstructive techniques are described, including available options and currently held views on indications and use of the best contemporary methods. It is essential for the physician to make a good initial decision on the need for primary amputation or limb salvage. A multidisciplinary approach is fundamental to successful salvage.     

The efficacy of the combined conservative therapy of patients with chronic obliterating arterial diseases of the extremities in outpatient practice

The paper provides the results of multimodality conservative therapy in 527 patients with chronic obliterating diseases of extremity arteries, which was performed in the outpatient setting. Factors influencing its efficiency were analyzed. The paper emphasizes the value of this direction of treatment whose underestimation sharply aggravates the prognosis of these diseases, including the results of their surgical management. Having obtained positive results in 84.5% of patients, the authors note the efficiency of treatment to be decreased with severe arterial insufficiency of lower extremities (5% of negative results in Stage IIa, 23% in Stage IIb, and 40% in Stage III), in patients with prior surgical interventions, and in elderly patients with atherosclerosis obliterans and younger patients with non-specific aortoarteritis.     

Salvage of failed amputation about the hip in peripheral vascular disease by open wound care and nutritional support

Five consecutive patients with wound and/or plastic surgical flap failure after hip disarticulation or amputation at the lesser trochanteric transfemoral level were treated with local tissue debridement, open wound management, culture-specific antibiotic therapy, and nutritional supplementation. All of the patients underwent amputation about the hip as a result of ischemic necrosis of the lower extremity. Four of the five patients were able to achieve wound healing by second intention. The fifth patient died 2 months after the surgery. None of the patients required revision surgery. One patient underwent split-thickness skin grafting to minimize the need for continued wound care. Local wound management combined with nutritional support and culture-specific antibiotic therapy is an acceptable alternative to major amputation stump revision in patients with potentially high morbidity who fail to heal after amputation about the hip.     

Critical limb ischemia

Chronic critical limb ischemia is defined as ischemia which generally endangers the distal part of a limb. If the ischemia is unrelenting, there is a high risk that amputation will be required. These critical limbs were amputated as an initial treatment long ago. Now it becomes clear that disabling patients have very poor quality of life after major amputation, and ischemic leg produces noxious substances which circulates whole body. So that primary amputation should not be a first choice for the most of the cases. And excellent techniques or new surgical materials bring successful vascular reconstruction to critical limb ischemia. Since we have not a clear definition, European and US criterion seems to be useful for a while. Macrocirculation is represented by ankle systolic pressure and microcirculation by transcutaneous oxygen pressure as well. Its value of les than 10 mmHg means urgent critical condition. Main surgical repairs include below knee bypass using autovein or fine profundaplasty with or without PTA. Usually patients should receive general cares because of high risks.     

Evolving role of CNSs in developing risk-anchored preventive interventions

Emerging emphases on systems of care, cost containment, and preventive interventions require the CNS to recognize risk factors and change health behaviors before complications develop. To lower substantially the rate of nontraumatic lower extremity amputation, high-risk populations must be screened and must receive appropriate management, including education and self-care interventions. In this article, two studies that examined foot risk factors in ambulatory elderly with intact feet are compared. American Diabetes Association and Gillis W. Long Hansen's Disease Center risk criteria were applied to both datasets. Recommendations for education, management, and referrals based on the calculated level of risk are presented.     

Very distal bypass for salvage of the severely ischemic extremity

Forty-six bypass grafts to tibial arteries distal to the ankle were performed in 35 patients for salvage of extremities threatened by gangrene or nonhealing ulcers (grade III, category 5) or ischemic rest pain (grade II, category 4). Most patients (80%) were diabetic, with severely calcified arteries, whom previously we would have considered as candidates for primary amputation. All reconstructions were performed with autologous saphenous vein. Inflow was from the common femoral artery in 5 (11%), the popliteal artery in 25 (54%), or the mid-tibial arteries in 16 (35%). Life-table analysis was used to calculate primary patency and limb salvage. Results were analyzed according to origin of inflow, outflow, or configuration of the conduit (in situ saphenous vein, n = 29 [63%], reversed saphenous vein, n = 11 [24%], or nonreversed saphenous vein, n = 6 [13%]). Overall cumulative primary graft patency at 2 years for all grafts was 72%, and the cumulative limb salvage rate was 89% for the same interval. No significant differences were seen in comparing grafts originating from the femoral or popliteal level with those arising from the tibial arteries. No significant differences were noted in graft patency or limb salvage among grafts with a posterior tibial, dorsalis pedis, or plantar artery outflow. No significant difference was noted between in situ saphenous vein grafts and reversed saphenous vein grafts. A significant decreased primary patency was noted for grafts performed with nonreversed, translocated saphenous vein. We conclude that bypass grafts to the ankle or foot vessels are beneficial and should be considered for limb salvage in extremities with gangrene, ischemic ulceration, or ischemic rest pain. In our experience, in situ saphenous vein grafts or reversed saphenous vein grafts performed similarly, whereas nonreversed saphenous vein grafts have a poorer prognosis. Vessel wall calcification requires a modification in technique for performance of these grafts but did not affect long-term performance or limb salvage, and thus should not be considered a contraindication to vascular reconstruction. The operative microscope was used in 61% (28 of 46) of these cases and found useful in creating these delicate anastomoses. Additional follow-up is needed to document the long-term results of these very distal reconstructions.     

Role of pulse spray thrombolysis in acute ischemia of the extremities--comparison of results with the low dose technique of local thrombolysis, embolectomy and thrombectomy

BACKGROUND: The reported mortality of patients suffering from acute limb ischemia is in the range of 10% to 30%, as is the incidence of amputation in the survivors. MAIN PURPOSE: The evaluation of the pulse spray thrombolysis (PST) role in the treatment of acute extremity ischemia originating from thrombosis or embolism of native artery or bypass graft. The comparison of PST with low dose technique thrombolysis (LD), thrombectomy (TE) and embolectomy (EE). METHODS: Ninety nine consecutive patients were evaluated during a two year interval (1994-1996). PST, resp. LD, TE and EE were the method of choice in 22, resp. 11, 35 and 31 patients of average age 58.3 +/- 13.7; resp. 60.0 +/- 8.9; 74.2 +/- 11.7; 76.9 +/- 9.3 years. The native artery was occluded in 15 (68.2%), resp. 8 (72.7%), 31 (88.6%) and 30 (96.8%) patients with PST, resp. LD, TE and EE treatment. The vascular reconstruction was occluded in the rest of the cases. The lower limb extremity arteries were occluded in 20 (90.9%) of patients indicated for PST, 10 (90.9%) for LD, 33 (94.3%) for TE and 26 (83.9%) for EE. The contraindication for local fibrinolysis was severely ischemic limb in which viability was imminently threatened. RESULTS: PST was successful in 19 (86.4%), LD in seven (63.4%), TE in 13 (37.1) and EE in 27 (87.1%) patients. The failure of procedure required amputation in one patient (4.5%) with PST, one (9.1%) with LD, nine (25.7%) with TE-p < 0.001 and two (6.5%) with EE. The mortality was 4.5% (one patient), resp. 0%, 28.6% (10 patients)-p < 0.001 and 3.2% (one patient) in PST, resp. LD, TE and EE. The long term results were better if the successful local fibrinolysis was combined with percutaneous transluminal angioplasty (PTA), stent implantation or small vascular reconstruction. CONCLUSION: PST is the method of choice in the treatment of thrombotic or embolic occlusion of native artery or bypass graft in condition of good limb viability where there is no danger of time delay. EE is indicated in limb embolism where the viability of extremity is threatened. Thrombectomy alone has no place in the treatment of artery or bypass graft thrombosis.     

A reevaluation of intraarterial thrombolytic therapy for acute lower extremity ischemia

PURPOSE: This study was performed to clarify the role of intraarterial thrombolytic therapy (IATT) in the management of acute lower extremity ischemia. METHODS: A retrospective review of 77 patients undergoing 84 courses of high-dose regional urokinase IATT from July 1981 to June 1991 was performed. The group included patients with acute thrombosis of lower extremity bypass grafts (n = 48) or native arteries (n = 36), presenting with ischemic but viable limbs, minimal or no motor dysfunction, and an absence of muscle rigor or compartment syndrome. The data were then examined individually by site of thrombosis to evaluate patient selection for IATT. RESULTS: Complete lysis, complications (either distal thromboembolism or bleeding), and early limb loss occurred in 59.5%, 11%, and 6% of infusions, respectively. IATT precluded the need for operative intervention in 49% of acutely ischemic limbs. When surgery was required, successful IATT precisely localized responsible lesions and reduced the magnitude of operation. A subset of 13 patients were identified in whom either no intrinsic abnormality or poor runoff were evident after lysis and were treated with anticoagulation alone. CONCLUSIONS: These data show IATT to be especially suitable for thrombosis of native iliac or femoropopliteal arteries and infrainguinal vein grafts. IATT serves primarily as an adjunct in management of acute lower extremity ischemia. After successful IATT, subsequent therapy can be tailored to the anatomic cause of thrombosis.     

Air bubbles in the subclavian or internal jugular veins: a common finding on contrast-enhanced CT

BACKGROUND: Foot complications in diabetes incur huge human and medical costs. There is a high incidence of complicated diabetes mellitus in Far North Queensland, particularly in the indigenous communities. METHODS: An audit of 51 patients admitted to Cairns Base Hospital from July 1992 to December 1994 with diabetic foot complications requiring surgical intervention was performed. RESULTS: The majority of surgical procedures were for serious infections in neuropathic feet precipitated by minor trauma. Surgical procedures included debridement/drainage, minor amputation, major amputation and arterial bypass. Half of the patients required more than one procedure and/or multiple admissions. Average length of stay was 48 days. Indigenous patients were overrepresented in this audited group. CONCLUSIONS: Prevention or minimization of diabetic foot complications can be achieved only through improvement in education and vigilance at all levels of the treatment process from community to hospital. Special attention to the needs of indigenous communities with a high incidence of diabetes must be a feature of any future initiatives.     

Cortisone-induced osteoporosis: effects on bone adenylate cyclase

The majority of patients with soft tissue or bone sarcomas of the upper extremity can be treated today with limb-saving procedures using combined modality therapies. For patients with a tumor in the shoulder area, sometimes an interscapulothoracic amputation is the only radical surgical treatment. However, in selected cases, in which the tumor does not involve the neurovascular bundle, a limb-sparing alternative might be the Tikhoff-Linberg resection. Normal function of the hand and forearm, with reasonable function of the elbow, can be maintained by this procedure. Four case histories are reported.     

Can duplex scan arterial mapping replace contrast arteriography as the test of choice before infrainguinal revascularization?

PURPOSE: Arteriography is the diagnostic test of choice before lower extremity revascularization, because it is a means of pinpointing stenotic or occluded arteries and defining optimal sites for the origin and termination of bypass grafts. We evaluated whether a duplex ultrasound scan, used as an alternative to arteriography, could be used as a means of accurately predicting the proximal and distal anastomotic sites in patients requiring peripheral bypass grafts and, therefore, replace standard preoperative arteriography. METHODS: Forty-one patients who required infrainguinal bypass grafts underwent preoperative duplex arterial mapping (DAM). Based on these studies, an observer blinded to the operation performed predicted what operation the patient required and the best site for the proximal and distal anastomoses. These predictions were compared with the actual anastomotic sites chosen by the surgeon. RESULTS: Whether a femoropopliteal or an infrapopliteal bypass graft was required was predicted correctly by means of DAM in 37 patients (90%). In addition, both anastomotic sites in 18 of 20 patients (90%) who had femoropopliteal bypass grafts and 5 of 21 patients (24%) who had infrapopliteal procedures were correctly predicted by means of DAM. CONCLUSION: DAM is a reliable means of predicting whether patients will require femoropopliteal or infrapopliteal bypass grafts, and, when a patient requires a femoropopliteal bypass graft, the actual location of both anastomoses can also be accurately predicted. Therefore, DAM appears able to replace conventional preoperative arteriography in most patients found to require femoropopliteal reconstruction. Patients who are predicted by means of DAM to require crural or pedal bypass grafts should still undergo preoperative contrast studies to confirm these results and to more precisely locate the anastomotic sites.