Do graduated compression stockings and pneumatic boots have an additive effect on the peak velocity of venous blood flow?

Graduated compression stockings and intermittent pneumatic compression boots reduce the incidence of deep vein thrombosis. Recent studies suggest that the simultaneous use of these devices may have a synergistic prophylactic effect; however, conflicting reports also exist. Using duplex imaging, we analyzed the effect on peak venous velocity in the superficial femoral vein produced by the individual and simultaneous use of graduated compression stockings and intermittent pneumatic compression boots. Normal volunteers and postoperative patients were examined. The use of intermittent pneumatic compression boots significantly increased the peak venous velocity relative to rest, whereas the use of graduated compression stockings did not alter the peak venous velocity. Also, the addition of graduated compression stockings to legs already being treated with intermittent pneumatic compression boots did not produce a further augmentation of peak venous velocity. This study demonstrates that the simultaneous use of graduated compression stockings and intermittent pneumatic compression boots does not produce a synergistic augmentation of peak venous velocity in the superficial femoral vein.

Axillary artery compression and thrombosis in throwing athletes.

A 28-year-old major league baseball pitcher sustained an axillary artery thrombosis which was successfully treated with intraarterial urokinase. Subsequent angiography and duplex scanning with the arm elevated in the pitching position demonstrated inducible compression of the axillary artery by the humeral head as well as compression at the thoracic outlet. To determine the incidence of axillary and subclavian artery compression and to investigate the mechanism of injury, brachial artery blood pressures and duplex scans of the subclavian and axillary arteries were performed in both the neutral position and the throwing position in the 92 extremities of 19 major league baseball pitchers, 16 non-pitching major league players, and 11 nonathlete controls. A drop in blood pressure of greater than 20 mm Hg was noted in the position in 56% of extremities tested, with a loss of a detectable blood pressure in 13%. Compression of the axillary artery by the humeral head was documented in 83% of extremities, but in only 7.6% was a greater than 50% stenosis inducible. No statistical difference was found in the incidence of arterial compression between the three groups tested or between their dominant and nondominant extremities. Dissection of the axillary artery in two cadavers documented that abduction and external rotation of the arm causes compression of the axillary artery by the humeral head, which acts as a fulcrum. We conclude that the repetitive mechanical trauma of the throwing motion can cause intermittent compression and contusion of the axillary artery by the humeral head and predisposes the athlete who throws to thrombosis of the axillary artery.

Suspected deep vein thrombosis. Management by impedance plethysmography.

Controversy exists as to whether patients suspected of having deep vein thrombosis (DVT) can be studied safely without venography, with its attendant expense, inconvenience, and potential risk. We used impedance plethysmography (IPG) in 1,464 consecutive patients suspected of having DVT, with 96% of these patients with normal IPGs, there were no fatal pulmonary emboli (PE). The incidence of nonfatal PE was 1%. In 284 outpatients suspected of having DVT, but discharged without treatment because of normal IPGs, only one patient returned with subsequent symptoms of DVT (0.4%). Noninvasive testing with IPG is a safe and highly cost-effective alternative to venography for routine management of patients suspected of DVT.

Noninvasive detection of carotid stenosis following endarterectomy.

Noninvasive diagnostic studies (oculoplethysmography, pulsed Doppler arteriography, and phonoangiography) were used to follow the postoperative courses of 172 patients who had 199 carotid endarterectomies. There were 24 restenotic arteries in 21 patients who underwent 29 operations. Fifteen restenotic lesions in 14 patients were detected solely by noninvasive testing. These patients are being observed closely and remain asymptomatic. One has been operated on for progression of disease. Either transient or permanent neurologic deficits developed in nine as the initial indication of recurrent stenosis or occlusion; three of these subsequently have undergone reoperation. Patients with bilateral disease are at increased risk of restenosis. Routine testing of all patients undergoing carotid endarterectomy is recommended 1, 3, and 12 months postoperatively to detect and observe stenosis on both the side operated on and the contralateral side before clinical symptoms develop.

Applicability and interpretation of electrocardiographic stress testing in patients with peripheral vascular disease.

Electrocardiographically monitored arterial stress testing was performed before surgery in 130 patients with peripheral vascular disease. When limitations of claudication or pain at rest precluded treadmill exercise, arm ergometry was employed. The electrocardiographically monitored arterial stress test proved a cost-effective, easily applicable means of screening for coronary artery disease in this group of patients. Unlike statistical analyses of historical risk factors, the electrocardiographically monitored arterial stress test evaluates the current functional state of the myocardium. We believe that preoperative electrocardiographic exercise testing should be employed more widely and should be considered in any patient facing major surgery in whom coronary artery disease is suspected on the basis of past history or known risk factors. In patients who have an ischemic response to exercise, particularly at less than 75 percent of the maximum predicted heart rate, coronary angiography and possibly coronary revascularization should be considered before elective major surgery is performed.

Assessment of operative risk with electrocardiographic exercise testing in patients with peripheral vascular disease.

Doppler ankle blood pressures were performed inere obtained in 100 consecutive patients with peripheral arterial insufficiency after treadmill exercise. A twelve lead electrocardiogram was monitored during and after exercise. Despite a restricted ability to exercise because of peripheral vascular insufficiency, forty-six patients had ventricular dysrhythmia or ischemia, or both, usually without associated symptoms. Electrocardiographic monitoring during treadmill exercise proved a useful predictor of postoperative complications. Thirty-two vascular operations were performed in patients with no electrocardiographic evidence of ischemia. No patient had a postoperative myocardial infarction or died. Sixteen vascular procedures were performed in patients with ischemic responses on exercise electrocardiography. Six patients had postoperative myocardial infarctions, two of which were fatal. Electrocardiographic monitoring during treadmill exercise for peripheral vascular insufficiency in recommended (1) to assess the severity of coronary artery disease and the likehood of postoperative complications, and (2) as a precautionary measure to identify potentially dangerous dysrhthmias or ischemia during exercise before the development of clinical symptoms.