Autonomic arterial neuropathy in lower limbs.

AIM: This prospective and controlled study was carried out to show the role of hyperperfusion due to decreased arterial resistance in patients with arterial neuropathy of lower limbs. METHOD: Arterial Duplex color scanning and magnetic resonance imaging (MRI) angiography were made in 54 patients with lower limb venous stasis in which Pulsatility Index (PI) from pedal arteries by using CW Doppler was below cut off value of 5 as a confirmatory evidence of autonomic neuropathy and in 24 healthy subjects. RESULTS: PI was mean 2.79 ranged from 4.87 to 0.82 in patients. It was mean 9.38 between 5.43 and 15.25 in control subjects. PSV was found mean 44.52 cm/sec ranged from 26 to 74 cm/s in patients. It was found between 10 and 23 cm/sec with average 16.08 cm/s in healthy ones. In addition to venous duplex scanning findings, MRI angiography demonstrates arterial contrast enhancement, vascular blush, early venous filling and permanent venous dilatation in 16 patients (group 2) having PI below 3 with severe degrees of hyperperfusion. In this group, PI was mean 1.70 ranged from 2.46 to 0.82 and PSV was mean 61.19 cm/s, between 53 to 74 cm/s. Out of patients, 38 (group 1) had no pathological findings in MRI angiography and had PI>3 and <5. In this group, PI was mean 3.26, ranged from 4.87 to 2.55 and PSV was mean 37.5 cm/s, between 26 to 47 cm/s. CONCLUSION: In this trial, we observed that patients with arterial neuropathy in the leg (groups 1 and 2) had a significant increase in PSV and a decrease in PI values from foot arteries compared with that of the control group (P=0.001). A remarkable difference was found in parameters between patient groups (P=0.001). Finally, it can be said that lower limb hyperperfusion owing to arterial neuropathy in various degrees produce venous stasis and is also responsible for some venous abnormalities.

Dorsal pedal venous oximetry as an outcome index of lower extremity revascularizations.

Dorsal pedal venous blood gas analysis was performed in 24 patients with arterial occlusive disease requiring revascularizations of the lower extremities. After the reconstructive surgical procedure, measurements were repeated. It has been observed that this method is useful before surgery since it proves the severity of tissue hypoxia due to perfusion impairment of the foot. Postoperative measurements have detected the effectiveness of the vascular restorations. The results of the trial showed a mean increase in partial pressure of venous blood oxygen (PVO2) and pH of 30.3% and 13.7% (p<0.05), respectively and a mean decrease in partial pressure of arterial carbon dioxide (PCO2) of 12.9% (p<0.05) between initial and postsurgical measurements in involved legs. In the healthy, unoperated on side, there was no significant (p>0.05) change in response to arterial reconstructions. Symptoms decreased markedly in direct proportion to the increase in dorsal pedal venous PO2 induced by changes in blood flow. This method can be reliably used for assessing the treatment to ensure adequate oxygen delivery to the foot as a result of improved pedal perfusion.

Early decortication for postpneumonic empyema in children. Effect on pulmonary perfusion.

Early pulmonary decortication was performed on 66 of 137 children with postpneumonic empyema, while 71 received conventional treatment. The mean age of the 66 patients with decortication was 5.5 years (range 6 months-14 years). The empyema was left-sided in 34 and right-sided in 32. Decortication was performed when lung expansion was not obtained after 10-12 days of intercostal tube drainage, antibiotic therapy (guided by sensitivity tests of pleural fluid) and pleural irrigation. Scintigraphy showed loss of pulmonary perfusion on the side of empyema to be 65% +/- SD 20 (25-98)% before decortication in the 23 tested patients. In ten of them the test was repeated after surgery and showed significant (p < 0.001) diminution of the perfusion defect, from 57 +/- 6.8 (25-84)% to 4 +/- 2.6 (0-8)%. The hospital stay was significantly (p < 0.001) shorter for the surgically treated than for the classically managed patients, viz. 19.5 +/- 4 (13-36) days vs 73.6 +/- 14 (34-110) days. Early decortication thus had beneficial effects on pulmonary perfusion and hospital stay.

Peripheral vascular injuries in children.

We report 94 arterial injuries in 91 children treated at the Department of Thoracic and Cardiovascular Surgery, Medical School of Dicle University, between 1978 and 1988. The average age was 10.3 (range, 3 to 14) years. Stab wounds were seen in 37 patients (40%). Gunshot wounds were seen in 21 patients (23%), and two cases were caused by iatrogenesis. Vein damage was present in 39 patients (44.4%), and nerve loss was observed in 20 patients (21.2%). Twenty-one cases (23.3%) were associated with fractures. Diagnosis of arterial injury was made by clinical findings. Arteriography was used in 15 patients (16.5%) as the diagnostic method. The surgical interventions performed for arterial repair in our series were end-to-end anastomosis in 61 (64.5%), interposition of autogenous reversed saphenous vein grafts in 22 (23.4%), lateral suture in 8 (8.3%), and ligation in 3 (3.9%) patients. Four patients (5.3%) underwent limb amputation.

Vascular injuries and amputation following limb fractures.

Sixty-seven cases treated for peripheral vascular injuries associated with fractures between the years of 1977 and 1988 in the Department of Thoracic and Cardiovascular Surgery of the Dicle University, Faculty of Medicine, were reviewed retrospectively. The cause of injury was blunt trauma in 37 cases (55%) and penetrating wounds in the others, 29 gunshot injuries and one case with a stab wound. The maintenance of vessel continuity was aimed at in all patients. The ratio of limb amputation was 13% in patients operated upon within the first 8 hours after the injury. The same ratio was 39% in cases where the surgical intervention was delayed beyond 8 hours.