Assessment of generic health-related quality of life in patients with intermittent claudication.

OBJECTIVES: to measure quality of life in patients with intermittent claudication and evaluate the ability of patients and vascular surgeons to make a similar assessment. DESIGN, MATERIALS AND METHODS: in this prospective study patients with intermittent claudication attending two vascular clinics were asked to complete a generic health-related quality of life instrument (MOS SF-36). Patient quality of life and vascular surgeons' assessment of patient quality of life were further evaluated using a single question/adjectival scale response combination. RESULTS: patients' self-assessment of their quality of life correlated better with the SF-36 score than did the surgeons' assessment. There was little correlation between the surgeons' and patients' own assessment of quality of life. The surgeons differed significantly from each other in their assessments. Claudicants had lower SF-36 scores than population norms in pain and physical aspects of quality of life. CONCLUSIONS: claudicants have worse quality of life than the general population, with pain and physical limitations being the most important domains. Surgeons predict the quality of life of claudicating patients less accurately than patients do themselves, and may differ from their colleagues in such assessments. Objective quality of life assessment in claudicants should be undertaken before treatment is decided.

Fate of the iliac arteries after repair of abdominal aortic aneurysm with an aortobifemoral bypass graft.

The objective of this study is to determine the fate of the iliac arteries after repair of abdominal aortic aneurysm with an aortobifemoral bypass graft. It is a prospective natural history study at a university-affiliated urban teaching hospital. Thirty-two patients with retrograde flow to the iliac circulation after repair of an abdominal aortic aneurysm by aortobifemoral bypass grafting were studied. All patients were followed prospectively with repeat CAT scans, clinical assessment, and selective angiography to determine the fate of the iliac circulation. We were particularly interested in subsequent vessel thrombosis or aneurysmal dilation. Patient survival was analyzed with a Kaplan-Meier life-table and survival curve. Graft patency was analyzed using life-table analysis. Primary outcomes included iliac artery size, graft patency, and patient survival. The iliac arteries remained constant in size or thrombosed in all study patients. Iliac expansion did not occur in any of the study patients. Secondary graft patency was 100%. The cumulative survival rate at 47 months was 0.55 (0.37-0.74, 95% confidence interval). Retrograde perfusion of diseased iliac arteries after aortobifemoral bypass for repair of abdominal aortic aneurysm is safe. Iliac artery atherosclerotic, ectatic or small aneurysmal disease (< or = 3 cm) does not appear to be a contraindication to retrograde iliac artery perfusion.

Management of subclavian-axillary vein thrombosis: a review.

OBJECTIVE: To study, by literature review, the management of subclavian-axillary vein thrombosis (SAVT) and to make recommendations. DATA SOURCES: The MEDLINE database and cross-referenced articles. STUDY SELECTION: Key words subclavian-axillary vein thrombosis, venous thrombosis, Paget-Schroetter syndrome, anticoagulation, and thrombolysis were used to extract articles related to SAVT. DATA EXTRACTION: Independent extraction of articles by 2 observers. DATA SYNTHESIS: Although numerous studies are available in the literature, they vary widely in their patient selection, treatment methods, follow-up and conclusions. As such, the management of patients with SAVT remains controversial. CONCLUSIONS: Anticoagulation remains the initial treatment of choice for acute SAVT although there is definitely a role for thrombolysis and surgery in selected cases. Surgical intervention should be reserved for patients in whom there is a specific indication. Since chronic symptoms depend largely on the etiology of the disease, treatment should be tailored to address the causative factors. A multicentre, prospective study is necessary to evaluate the optimum management strategies for patients with SAVT.

Conservative management of chylous ascites complicating aortic surgery: a case report.

Chylous ascites is an uncommon complication of aortic surgery. In the past, operative management was the standard therapy. A 62-year-old man with chylous ascites was treated successfully with paracentesis and total parenteral nutrition alone. A review of the recent literature suggests that a preliminary course of conservative therapy can limit the need for operative intervention to those who fail the primary conservative treatment.

Metastatic testicular tumor requiring inferior vena cava resection.

A patient undergoing radical retroperitoneal lymphadenectomy for metastatic embryonal cell testicular carcinoma is presented. Tumor resection required removal of the inferior vena cava due to transmural invasion. The inferior vena cava was replaced using externally stented polytetrafluoroethylene (PTFE) graft. Patency was documented by postoperative Doppler studies, duplex scanning, and computed tomographic scanning. Stented PTFE is currently the graft of choice for inferior vena caval replacement.

Intra-arterial infusion of urokinase for acute, critical ischemia in the lower limb.

OBJECTIVE: To assess the value of intra-arterial urokinase infusion in the management of acute, critical ischemia of the lower limb. DESIGN: A prospective study. SETTING: A vascular surgery department within a university hospital. PATIENTS: Twenty-five consecutive patients with acute, critical ischemia of the lower limb, excluding those requiring immediate surgical intervention. Follow-up ranged from 1 to 18 months. INTERVENTION: Angiography followed by intra-arterial infusion of urokinase. MAIN OUTCOME MEASURES: Angiographic and clinical evidence of clot lysis and limb reperfusion, any surgical procedures required and final clinical outcome. RESULTS: Urokinase was technically successful in lysing clot in 19 patients: 7 required no further treatment; in 8 an underlying lesion was identified and repaired by either percutaneous angioplasty or surgery; in the remaining 4 patients, although the clot was lysed, the limbs remained ischemic and, since reconstruction was considered impossible, amputation was required. Two patients improved clinically with little angiographic evidence of clot lysis. A total of nine patients required amputation, seven of these as a "primary" procedure after urokinase infusion. There were four episodes of significant morbidity but no deaths. CONCLUSION: Urokinase has a place in the management of acute vascular occlusion of the lower limb, not only in treating the occlusion but, equally importantly, in facilitating identification of lesions that require surgical intervention.

Ischemic damage to the spinal cord following end-to-side aortobifemoral bypass.

A patient presenting with urinary retention was found to have progressive spinal cord ischemia subsequent to an end-to-side aortobifemoral bypass for atherosclerotic disease. This serves as a vivid reminder of the possibility of this complication even in ischemic disease and that urinary retention may be the initial symptom of cord ischemia. A review of the literature on spinal cord ischemia following abdominal aortic surgery is presented.

Nonanastomotic pseudoaneurysm of expanded polytetrafluoroethylene axillofemoral bypass graft.

A case of nonanastomotic pseudoaneurysm of a unilateral axillofemoral bypass graft is reported. The graft material used in this particular instance was an 8 mm, reinforced, thin-walled, fluorinated ethylene-propylene-ringed, expanded polytetrafluoroethylene (ePTFE). The pseudoaneurysm occurred 1 year after insertion of the graft and was not associated with any direct trauma. It manifested with a painful tender mass at the top of the body of the axillofemoral bypass graft at the level of the nipple line. There were no symptoms of localized or diffuse sepsis. Immediate surgical exploration confirmed the diagnosis of a pseudoaneurysm of the ePTFE graft. Successful repair of the disrupted segment was accomplished by use of an interposition, nonringed, reinforced, thin-walled, 8 mm ePTFE graft. To our knowledge this is the first case of a nonanastomotic pseudoaneurysm of a ringed, ePTFE, axillofemoral bypass graft not associated with direct trauma.

Ruptured Baker's cyst causes ecchymosis of the foot. A differential clinical sign.

Three consecutive patients with ruptured Baker's cysts, verified by duplex scan, were found to have ecchymosis on the dorsum of the foot. The appearance of ecchymosis can be helpful in differentiating a ruptured cyst from cellulitis or deep-vein thrombosis.

Aortobifemoral bypass--an enduring operation.

Aortobifemoral bypass (ABF) has been available as a method for treating patients with aortoiliac occlusive or aneurysmal disease for 40 years. ABF has been successful in alleviating the symptoms of claudication and critical ischemia. The long-term patency rates have been excellent with low operative morbidity and mortality. Major improvements have been made in indications, preoperative assessment and operative and postoperative care. With careful follow-up the natural history of a patient who undergoes ABF is known. Predicting outcome is now possible and a cost:benefit analysis can be made. ABF has proved to be a successful and enduring procedure.

Vascular injury and repair associated with retroperitoneal lymphadenectomy for nonseminomatous germinal cell tumours of the testis.

Metastatic disease adjacent to major vascular structures in the retroperitoneum sometimes necessitates planned removal of portions of these vessels, or the vessels may inadvertently be injured when retroperitoneal lymphadenectomy is performed. In 78 patients who underwent retroperitoneal lymphadenectomy, 17 (22%) required vascular repair intraoperatively. The vena cava was most frequently involved (eight cases) followed by inadvertent injury to the renal arteries (five cases) or the infrarenal aorta (three cases). Resection of the infrarenal aorta was planned in two cases without postoperative complication. In six cases a resection of either the whole inferior vena cava or a portion of it was needed to remove all of the tumour. There were nine cases of inadvertent injury to the aorta, vena cava or a renal artery. The outcome after arterial repair was satisfactory with the exception of the inadvertent renal artery injuries, which required nephrectomy in three cases. Leg swelling was not a long-term sequela of either caval repair or resection.

End-to-end versus end-to-side proximal anastomosis in aortobifemoral bypass surgery: does it matter?

The proximal anastomosis is still a controversial issue in vascular surgery. To compare end-to-end (EE) and end-to-side (ES) proximal anastomoses, the authors undertook a prospective study with 3 years' follow-up involving 120 patients, all of whom had aortobifemoral bypass. Fifty-one (42.5%) patients received the EE and 69 (57.5%) the ES anastomosis. The indications for surgery were abdominal aortic aneurysm (EE 51%, ES 0%; p less than 0.05), claudication (EE 33.3%, ES 53.6%; p less than 0.05) and critical ischemia (EE 15.7%, ES 46.4%; p less than 0.05). Patients in the EE group were older (mean age: EE 66.1 +/- 2.8 years, ES 60.9 +/- 1.1 years; p less than 0.05) and had more ischemic heart disease (EE 39.2%, ES 27.5%; p less than 0.05). Postoperative mean increases in transcutaneous oximetry (EE 15.5 +/- 3.9 mm Hg, ES 12.6 +/- 2.3 mm Hg) and the ankle-brachial pressure index (EE 0.34 +/- 0.05, ES 0.30 +/- 0.03) were not significantly different in the two groups. The operative death rate was higher for the EE group (EE 11.8%, ES 1.4%; p less than 0.05). Early thrombosis occurred in six patients, two in the EE group and four in the ES group. Computed tomography, done 1 year postoperatively in 95 patients, revealed two small (less than 3 cm) distal anastomotic dilatations, one in each group. At 3 years, cumulative survival and patency were similar in both groups. The authors conclude that the two anastomotic groups had very similar short- and long-term results, except for the operative death rate which was higher in the EE group.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravenous digital subtraction arteriography in the evaluation of vascular grafts.

Between 1982 and 1986 intravenous digital subtraction arteriography was used to evaluate vascular grafts in 97 patients (54 males, 43 females). Indications included recurrent symptoms, absent or diminished pulses, a drop in Doppler pressure measurements, and clinical uncertainty with respect to graft patency. Problems identified included graft stenosis, stenosis of the anastomosis or its distal vessels, false aneurysm, arteriovenous fistula and emboli. Forty-eight operations were carried out following intravenous digital subtraction arteriography, and radiographic findings were verified surgically. Twice, intravenous digital subtraction arteriography did not show significant graft findings which were discovered at surgery. Thus intravenous digital subtraction arteriography showed a sensitivity of 95.8% and specificity of 100%. Complications following intravenous digital subtraction arteriography were: two patients developed urticaria, and one superficial thrombophlebitis. There were no cases of pulmonary edema or death. In conclusion intravenous digital subtraction arteriography is very useful in the diagnosis of graft-related problems if done on a selective basis looking at graft and anastomosis site only. Intravenous digital subtraction arteriography is done on an outpatient basis, has high sensitivity and specificity, good patient acceptance, is safe, fast and is less expensive than conventional arteriography.

Giant cell arteritis presenting as limb claudication. Report and review of the literature.

Upper limb claudication and pulselessness is an uncommon presentation of giant cell arteritis (GCA), often resulting in delayed diagnosis. We describe such a case diagnosed by angiography, in which a temporal artery biopsy showed classic GCA, despite the absence of local signs or symptoms. A review of 26 similar cases revealed that in 81% of patients where the only manifestation of GCA was upper limb findings, temporal artery biopsy yielded positive findings. Steroid therapy clinically improved 24/26 patients. These findings suggest that a consideration of temporal artery biopsy early in the investigation will hasten diagnosis and appropriate therapy.

The role of central haemodynamic monitoring in abdominal aortic surgery. A prospective randomised study.

To test the hypothesis that central haemodynamic monitoring is not necessary in all patients undergoing abdominal aortic surgery, a prospective randomised study in 40 consecutive patients undergoing elective abdominal aortic surgery was carried out. Patients with unstable angina, recent myocardial infarction (less than or equal to 6 months), and left ventricular ejection fraction (LVEF) less than 0.50 were excluded. Twenty-one patients had perioperative central haemodynamic monitoring while 19 patients had central venous pressure monitoring alone. Parameters studied included, perioperative haemodynamics and fluid balance, perioperative cardiac drug administration, operation time and clamp time, postoperative renal function, incidence of postoperative ventilation and line complications, duration of hospital and ICU stay, and 30 day postoperative outcome. Results obtained were compared with a high risk group of patients (LVEF less than 0.50) undergoing similar surgery. Statistical analysis failed to show any difference in outcome for any variable measured in either low risk group. All serious postoperative cardiac complications occurred in patients with LVEF less than 0.50 (P less than 0.0001). These data suggest that patients with LVEF greater than or equal to 0.50 are at low risk of developing postoperative cardiac complications and can be successfully managed perioperatively without the added potential risks and costs of central haemodynamic monitoring.

Is tube repair of aortic aneurysm followed by aneurysmal change in the common iliac arteries?

To address the concern that tube repair of an abdominal aortic aneurysm might be followed by aneurysmal change in the common iliac arteries, 23 patients who had undergone the operation were re-examined 3 to 5 years later. Although 9 had had minimal ectasia of these arteries preoperatively, in none of the 23 was there symptomatic or radiologic evidence of aneurysmal change on follow-up. Measurements of the maximum intraluminal diameters were made by computed tomography; they indicated no significant differences between the preoperative and follow-up sizes of the common iliac arteries. The variation in time to follow-up also showed no significant correlation with change in artery diameter.

The influence of central haemodynamics on transcutaneous oxygen (TcpO2) measurements.

Transcutaneous oxygen measurements (TcpO2) have been shown to be an index of tissue perfusion and it has been suggested that the main haemodynamic variable influencing tissue perfusion is cardiac output, assuming that inspired oxygen remains constant. To investigate this hypothesis we studied 23 consecutive patients in order to identify if changes in cardiac output correlated with similar changes in TcpO2 measurements. No correlation was found to suggest that cardiac output was the main haemodynamic determinant of TcpO2 measurements.

The effect of femoral arteriography on the incidence of groin contamination and postoperative infections.

A prospective study is presented on the effects of preoperative femoral arteriography on bacterial contamination and postoperative wound complications from groin incisions. Forty-four femoral reconstructive procedures (88 groin incisions) for aortoiliac disease were performed. Positive cultures occurred in 43.2% of patients and in 30.7% of the 88 incisions. There was no correlation found between the site of arteriography and positive cultures (Spearman correlation coefficient, p greater than .10). No correlation was found between the presence of hematoma due to arteriography and subsequent positive groin culture (Spearman correlation coefficient, p greater than .10). A higher incidence of positive cultures did occur for patients who had a difficult arteriographic procedure (Fisher's exact test, p = .020) or whose reconstructive procedure was greater than four hours (Fischer's exact test, p = .047). Seven patients had postoperative groin wound complications (15.9%), including three lymph leaks (6.8%) and four confirmed or suspected infections (9%). There were no graft infections. No correlation was found between the site of arteriography and the site of wound complication (Spearman correlation coefficient, p greater than .10). Neither positive culture results nor difficult arteriography nor presence of hematoma were accurate predictors of postoperative wound complications. We conclude that transfemoral arteriography does not increase the risk of complications of arterial reconstruction involving a femoral anastomosis.

Failure of bicycle exercise electrocardiograms to predict major post-operative cardiac complications in patients undergoing abdominal aortic surgery.

To determine if exercise electrocardiograms (EECGs) are justified in routine pre-operative screening for cardiac disease, we performed a prospective study on 77 consecutive patients scheduled for infrarenal aortic reconstructive surgery. All patients had EECGs performed 1-12 days prior to elective surgery. In addition to routine clinical assessment of cardiac disease, all patients were allocated a Goldman risk score. Four patients developed major post-operative cardiac complications of whom one patient died. EECG was not a significant predictor of outcome, as 48.6% of all EECGs were inadequate due to non-completion of the exercise protocol. Significant pre-operative predictors of outcome were a history of angina (p less than 0.01), myocardial infarction (p less than 0.001), congestive cardiac failure (p less than 0.0001), or a Goldman score of greater than 14 (p less than 0.05). By multivariate analysis of the pre-operative risk factors a history of congestive cardiac failure was found to be the most significant independent predictor of post-operative cardiac complications.