European journal of vascular surgery最新文献

This prospective study was designed to establish whether vascular endoscopy would provide more information on the graft lumen than standard completion angiography during infrainguinal bypass surgery. Ninety-nine patients with 102 infragenicular bypass grafts who underwent both angiography and angioscopy intraoperatively were evaluated. In 99 of the 102 patients the indication was critical limb ischaemia. Of the 102 bypass grafts, 81 were autogenous vein. Distally, 24 grafts were anastomosed to the below-knee popliteal segment, 64 extended to the crural and 14 to the pedal arteries. On completion of the distal anastomosis, grafts were first evaluated by angiography and then by angioscopy. The images obtained with the two monitoring modalities were compared by the operating surgeon and re-explorations were performed immediately if necessary. Completion angiography and angioscopy produced images of good quality in 96 and 97 cases, respectively. In 12 cases completion angiography showed abnormalities. Of these, five were located below the distal anastomosis and were not accessible to angioscopic examination. Conduit defects were found in seven instances. In one of them angioscopy showed the angiogram to be false-positive. Of the 90 grafts with normal completion angiograms, seven were found to show significant pathology on angioscopy. Compared to angioscopy, the sensitivity and specificity of angiography to detect abnormalities within the graft was 46% and 98%, respectively. Our results suggest that vascular endoscopy is superior to angiography for disclosing conduit defects, but that it does not provide adequate information about the distal arterial anatomy.

There are a number of methods of evaluating digital blood flow in the vascular laboratory but none fulfills the criteria of providing a quick and reproducible diagnostic test for Raynaud's phenomenon. We present our experience with the use of high frequency ultrasound to provide direct real time imaging of the digital arteries. Using this method and a standardised cold challenge test, consisting of exposure of the hand to a temperature of 10°C for 5 minutes, it is possible to distinguish patients with Raynaud's phenomenon from normal controls on the basis of extent of digital artery closure. The mean fall in digital artery diameter on cold challenge, expressed as a percentage of the original diameter, was 92.4% (s.d. = 16.4, s.e.m. = 2.1) in patients with Raynaud's phenomenon as against 8.7% (s.d. = 11.5, s.e.m. = 2.5) in a group of normal volunteers. Using a 45% fall in digital artery diameter as the diagnostic cut-off point, the test has a specificity of 100% and a sensitivity of 96.6% in differentiating patients with Raynaud's phenomenon from controls. It is suggested that the test could be used as objective confirmation of a clinical diagnosis and to assess the efficacy of therapeutic interventions.

Objective:

To evaluate the risk of pulmonary embolism (PE) despite adequate heparin therapy in a large series of patients with acute deep venous thrombosis and/or pulmonary embolism.

Design:

Prospective study.

Setting:

University Hospital Germans Trias i Pujol, Badalona, Spain.

Materials:

348 patients admitted because of deep venous thrombosis in the lower limbs and/or pulmonary embolism. A baseline lung scan was obtained initially in every patient, whether the original diagnosis was PE or deep vein thrombosis (DVT). Repeat chest X-ray and lung scans were obtained routinely at 8 days of heparin onset.

Outcome measures:

The primary trial endpoint was a finding of confirmed, clinically apparent recurrent PE; in addition, laboratory evidence of subdinical PE at the repeat scan was also considered.

Results:

PE recurrences were found in 23/348 patients (7%). No significant differences were found in age and sex distribution, or in the degree of DVT proximity between patients who developed and those who did not develop recurrences. Recurrent PE was more commonly found in patients with scintigraphic evidence of PE on admission, irrespectively of the original diagnosis being DVT or PE (18/151 vs. 3/155; p = 0.0005, Fisher's exact test). Recurrences were also more common in patients in whom thrombosis developed in the absence of any known risk factor (10/70 vs. 13/278; p = 0.007). The logistic regression analysis confirmed the statistical significance of these two clinical variables.

Conclusions:

Pulmonary embolism despite adequate heparin therapy is not an uncommon event. It appears possible to identify a subgroup of patients at a higher risk, and, modify treatment accordingly.

Objectives:

To determine time trends and geographical variations in the incidence of major amputation for peripheral arterial disease and whether lower rates of amputation were related to higher rates of arterial reconstruction.

Design:

Analysis of Scottish hospital discharge data.

Setting:

Scotland 1981–1990.

Materials:

Patients undergoing major amputation or arterial reconstruction for peripheral arterial disease.

Chief outcome measures:

Time trends in age-sex standardised rates of major amputation and arterial reconstruction, and correlation between the rates of these operations by health board.

Main results:

In Scotland, between 1981 and 1990, the incidence of major amputation fell by 22% (p < 0.001). Inconsistencies were observed within different age-sex groups. In the population under 65 years of age the incidence of amputation fell by 45% (p < 0.001), whereas in those over 65 years the incidence increased by 54% (p < 0.001). Amputation rates fell in men but a paradoxical increase was observed in women. Between 1981 and 1990, rates of arterial reconstruction doubled (p < 0.001), with an increase in all age-sex groups. Rates of amputation and reconstruction varied between health boards of residence, with a positive correlation (r = 0.5) between rates of operations within health board. Therefore areas with higher reconstruction rates tended to have higher amputation rates.

Conclusions:

In Scotland, the incidence of amputation has fallen during a period when reconstruction rates have risen greatly. However inconsistencies in time trends by age-sex groups, and the lack of an inverse correlation by health board of residence, suggest that fewer amputations are unlikely to be due solely to an increase in reconstructive surgery.

Between 1988 and 1993, 17 (3%) out of a total 654 patients underwent reoperation for control of haemorrhage following repair of abdominal aortic aneurysm in a vascular surgery unit. The first operation was performed for rupture in 12 cases and electively in five. The incidence of reoperation for postoperative bleeding was 1.7% following elective operation and 3.3% following emergency operation. Case-controls, matched for sex and primary operation, were identified. The mortality rate in those requiring reoperation was 58% compared with 23% in the control group (p = 0.037). Seven patients suffered progressive deterioration and died in the early postoperative period. Of the remaining ten patients, four suffered unexpected serious complications; two a fatal cerebro-vascular accident (CVA), one a fatal myocardial infarction (MI) and the fourth a non-fatal CVA. The patients requiring reoperation had greater blood loss (p < 0.05), greater transfusion requirements and lower core temperatures (p < 0.05) at the end of their first operation than the control group. All except one of the patients who bled had evidence of coagulopathy and had lower platelet counts than the control group both before and after the first operation. At reoperation there were multiple minor bleeding points in 11 patients, no active bleeding points in two patients and a discrete bleeding point in four patients. In conclusion, re-operation for control of postoperative haemorrhage is an uncommon complication which is strongly associated with coagulopathy, may predispose to “rebound” postoperative thrombotic episodes, and carries a poor prognosis.

Objectives:

The aim of the study was to depict regional cerebral blood flow (rCBF) during carotid cross clamping using ^99mTechnetium-hexamethylpropylene amine oxime (^TcHMPAO). This tracer rapidly passes the blood-brain barrier and is retained for hours in the brain tissue. Injecting ^TcHMPAO during surgery and performing single photon emission computer tomography (SPECT) scanning shortly after the operation thereby pictures rCBF at the time of injection.

Design:

Ongoing prospective study.

Settings:

Departments of Vascular Surgery, Neurology and Anaesthesiology, University Hospital, Rigshospitalet, Copenhagen, Denmark.

Material:

15 patients who during a period of 4 months underwent carotid endarterectomy.

Chief outcome measures:

Prior to surgery rCBF was determined using ¹³³Xe and SPECT. Intraoperatively stump pressure was measured and a bolus of ^TcHMPAO was injected for later SPECT measurement.

Main results:

We found a significant correlation between stump pressure and enhancement of side-to-side asymmetry in rCBF due to carotid cross clamping. Pronounced variations were seen in which regions were deprived of perfusion during clamping.

Conclusion:

^TcHMPAO allows tomographic assessment of CBF during carotid surgery. This method may serve as a reference tool in future research on intraoperative cerebral haemodynamics.