Assessment of stenoses in the aortoiliac tract by calculation of a vascular resistance change ratio before and after exercise

Objectives:Intraarterial pressure measurement is the most reliable method to assess haemodynamically significant stenoses in the aortoiliac tract. We have tried to develop a simple and quick, non-invasive method to assess stenoses of this type.Design:Prospective semi-blinded clinical study.Methods:It was postulated that a haemodynamically significant aortoiliac tract stenosis would result in a lesser degree of vascular resistance decrease after vasodilatation, compared to patients only suffering from femorodistal stenoses. We approximated vascular resistance by: (brachial pressure-ankle pressure) / femoral artery mean Doppler velocity. By dividing vascular resistance at rest by vascular resistance after exercise, we calculated the Resistance Change Ratio (RCR).Patients and results:In 34 patients (50 legs) with arterial stenoses, the pressure gradient over the aortoiliac segment was compared to the RCR. Legs were divided in three groups: group 1 consisted of 22 legs that showed a pressure gradient > 10 mmHg at rest; group 2 showed a pressure gradient > 10 mmHg after papaverine; group 3 showed a pressure gradient of 10 mmHg or less. The median RCR was: 0.74 (range: 0.23–4.04) for group 1, 0.71 (range: 0.36–1.80) for group 2 and 0.93 (range 0.36–2.06) for group 3. There was no significant difference between the groups (p = 0.19).Conclusion:The RCR could not be used to accurately detect stenoses in the aortoiliac

Endoscopic versus open subfascial division of incompetent perforating veins in the treatment of venous leg ulceration: A randomized trial

AbstractPurpose: Subfascial division of incompetent perforating veins plays an important role in the surgical treatment of patients with venous ulceration of the lower leg. To minimize the high incidence of postoperative wound complications after open exploration, endoscopic approaches have recently been developed. We carried out a prospective, randomized comparison of open and endoscopic treatment of these patients that was aimed at ulcer healing and postoperative wound complications. Methods: Patients with current venous ulceration on the medial side of the lower leg were randomly allocated to open exploration by the modified Linton approach or endoscopic exploration by use of a mediastinoscope. Results: Thirty-nine patients were randomized, 19 to open exploration and 20 to endoscopic exploration. The incidence of wound infections after open exploration was 53%, compared with 0% in the endoscopic group (p < 0.001). Patients in the open group needed longer hospital stays (mean, 7 days; range, 3 to 39 days) than patients in the endoscopic group (mean, 4 days; range, 2 to 6 days; p = 0.001). Four months after operation, the ulcers of 17 patients (90%) in the open group and 17 patients (85%) in the endoscopic group had healed. During a mean follow-up of 21 months (range, 16 to 29 months), no recurrences were noticed in either group. Conclusions: Endoscopic division of incompetent perforating veins is equally as effective as open surgical exploration for the treatment of venous ulceration of the lower leg but leads to significantly fewer wound healing complications. Endoscopic division is therefore the preferred method. (J Vasc Surg 1997;26:1049-54.

The value of pre-operative ultrasound mapping of the greater saphenous vein prior to 'closed' in situ bypass operations

Objective: The aim of this study was to test pre-operative ultrasound mapping for the detection of duplications and narrow vein segments of the greater saphenous vein (GSV) used as bypass for occlusive arterial disease surgery. Patients and methods: In 44 patients pre-operative ultrasound findings of duplications and lumen assessment of the GSV were compared to the per-operative findings. Results: In nine patients (20%) the pre-operative ultrasound examination showed a duplication. Pre-operative ultrasound had missed a duplication in two cases but had instead shown a narrow segment in both. The pre-operative ultrasound assessment of lumen diameter showed a narrow lumen segment in 10 of the 44 patients. In one patient a per-operatively narrow lumen had not been seen on pre-operative ultrasound. Conclusion: Pre-operative ultrasound mapping of the GSV is a sensitive tool for detection of duplications and narrow vein segments. Since these anatomical variations provide important information for the vascular surgeon, before performing a 'closed' in situ bypass operation, pre-operative vein mapping should be considered when planning such a procedure

Subfascial endoscopic ligation in the treatment of incompetent perforating veins

Objectives: To assess the technique of subfascial endoscopic ligation of incompetent perforatory veins by use of a mediastinoscope. Design: Prospective open clinic study. Setting: Two Departments of Surgery. Materials and Methods: Thirty-eight consecutive patients (40 legs) with recurrent or protracted venous ulceration of the lower leg were treated. Through a short, transverse incision of the skin and fascia in the proximal ⅓ of the lower leg a mediastinoscope (length 18 cm, diameter 12 mm) is inserted after which the perforating veins are ligated by haemoclips under direct vision. Main Results: All legs showed signs of incompetent perforating veins by clinical examination, confirmed with continuous wave ultrasonography and in 31 legs there was associated deep vein incompetence. Sixteen patients had active ulceration at the moment of operation and 22 had a history of recent or recurrent ulceration. One patient developed an inflammatory reaction at the wound and in two legs a subfascial infection occurred, necessitating surgical drainage. No postoperative mortality was seen. All 16 ulcers healed within 2 months (mean: 34 days; range: 21–55 days). During a mean follow-up of 3.9 (range: 2–5) years only one out of 38 patients (2.5%) developed a recurrent ulcer. Conclusions: Subfascial endoscopic ligation of incompetent perforating veins by use of a mediastinoscope is a relatively simple technique with a low postoperative complication rate and a low recurrent ulcer rate which makes it a valuable method for treating incompetent perforating veins

A prognostic model for amputation in critical lower limb ischemia

In a (negative) multicenter randomized trial on management for inoperable critical lower limb ischemia, comparing spinal cord stimulation and best medical treatment, a number of pre-defined factors were analyzed for prognostic value. We included a radiological arterial disease score, modified from the SVS/ISCVS runoff score. The purpose of this analysis was to evaluate clinical factors and commonly used circulatory measurements for prognostic modeling in patients with critical lower limb ischemia. We determined the incidence of amputation and its relation to various pre-defined risk factors. A total of 120 patients with critical limb ischemia were included in the study. The integrity of circulation in the affected limb was evaluated on five levels: suprainguinal,infrainguinal, popliteal, infrapopliteal and pedal. A total radiological arterial disease score was calculated from 1 ( full integrity of circulation) to 20 (maximally compromised state). We used Cox regression analysis to quantify prognostic effects and differential treatment (predictive) effects. Major amputation occurred in 33% of the patients at 6 months and in 51% at 2 years. The presence of ischemic skin lesions and the radiological arterial disease score were independent prognostic factors for amputation. Patients with ulcerations or gangrene had a higher amputation risk (hazard ratio 2.38, p = 0.018 and 2.30, p = 0.036 respectively) as well as patients with a higher radiological arterial disease score (hazard ratio 1.17 per increment, p = 0.003). We did not observe significant interactions between prognostic factors and the effect of spinal cord stimulation. In conclusion, in patients with critical lower limb ischemia, the presence of ischemic skin lesions and the described radiological arterial disease score can be used to estimate amputation risk

946-103 Incremental Prognostic Power for Perioperative Cardiac Events of Clinical History and Semi·Quantitative Dobutamine Before Major Vascular Surgery

Using the presence of stress induced ischemia with dobutamine-atropine stress echocardiography (DSE) for predicting perioperative cardiac events (CE) in patients undergoing major vascular surgery has a high negative but low positive predictive value (PPV).Aim of the studyto improve the PPV of DSE by combining the value of clinical markers and DSE.Methodsin 300 consecutive patients clinical risk factors (diabetes, angina, Q waves on ECG, age&gt;70 years, and history of ventricular arrhythmias) where assessed. DSE results were analyzed by quantifying the extent and severity of new wall motion abnormalities (NWMA) at peak stress. Also, heart rate threshold (HR-Thres) at which NWMA occurred was noted. Low HR-Thres was defined as NWMA at&lt;70% of maximal age and sex related heart rate.Results27 CE occurred of which 5 cardiac deaths, 12 myocardial infarctions and 10 patients with unstable angina. One-hundred patients had no clinical risk factors, 200 one or more. All but 1 CE occurred in patients with 1 Or more risk factors. In 27 of 72 patients with a positive DSE a CE occurred (PPV 38%). Quantifying the extent and severity of NWMA at peak stress provided no additional information. The HR-Thres at which ischemia occurred improved PPV In 30 patients with a low HR-Thres, 20 CE occurred (PPV 67%). In the remaining 42 patients with a high HR-Thres, only 7 CE occurred (16%). The improvement of PPV from 38% to 67% is statistically highly significant (P &lt; 0.01). All patients with a fatal CE and 8 of 12 patients with a myocardial infarction had a low HR-threshold.Conclusions1) in patients with no clinical risk factors additional stress testing is not efficient. 2) in patients with one or more risk factors semiquantitative DSE allows stratification of patients in low, intermediate, and high risk groups for CE