Fasciotomy in vascular trauma: is it too much, too often?

Fasciotomy has been used as a prophylactic measure against development of compartment syndrome and as a treatment modality when the syndrome has developed in patients suffering vascular trauma. The hospital records of 36 patients who underwent surgical repair of their traumatic vascular injuries were reviewed. All 36 patients had at least one indication for fasciotomy at the time of repair; i.e., ischemic time of more than 6 hours or combined arterial and venous injury. Prophylactic fasciotomies were performed in 18 of the patients at the time of vascular repair; 18 did not have fasciotomies performed at the time of initial repair. The decision to perform a fasciotomy was made by the operating surgeon based on well-defined criteria. Hospital stay was significantly longer for the fasciotomy group. Four of the fasciotomy-related complications were infective in nature. Only one patient who did not undergo fasciotomy at the time of original repair developed a compartment syndrome during the postoperative period. Selective fasciotomy based on well-defined criteria instead of serial physical examinations or measurement of compartment pressures will effectively save limbs; there is an increased hospital stay.

Normal angiograms and carotid pathology.

Nonstenotic ulcerated atherosclerotic plaques of the carotid arteries may be associated with symptoms of transient ischemic attacks, amaurosis fugax, and stroke. Preoperative evaluation of patients with these symptoms has traditionally included ultrasound and arch aortography angiograms of the area of the carotid bifurcation. Recent evidence has shown that ultrasound is more accurate in detection and morphologic delineation of these nonstenotic lesions. We analyzed the hospital records of 21 patients with ultrasonographic evidence of disease in whom arteriograms were negative. The patient group comprised 15 men and six women, with an average of 66 years. All patients had symptoms of hemispheric transient ischemic attacks and were evaluated with B-mode ultrasound and arteriography. Ultrasound was positive and arteriogram "negative" in all of the patients (i.e., described by the radiologist as without hemodynamic significant disease or ulceration, or as normal). The ultrasound diagnosis was confirmed at operation with findings of 20 to 50 per cent stenosis and ulcerative plaques. At retrospective review of the arteriograms, three ulcerations were found in the 21 patients. We conclude that B-mode ultrasound better defines nonstenotic ulcerative lesions and decisions to perform carotid endarterectomy may be based on either positive test. An ulcerative plaque by B-mode ultrasound and appropriate symptoms, therefore, may not require angiography before operation.

Intraoperative intra-arterial urokinase infusion as an adjunct to Fogarty catheter embolectomy in acute arterial occlusion.

Sixteen patients, seven men and nine women (mean age of 66 years), with acute arterial ischemia were treated with operative thromboembolectomy by Fogarty catheterization and urokinase. Seven patients were diabetic, ten were hypertensive and six had prior vascular surgical treatment. The operative arteriograms confirmed vascular occlusive phenomenon. The ankle to brachial ratio was a mean of 0.02. Perioperatively, patients had anticoagulation with heparin systemically. All patients underwent transfemoral embolectomy using a Fogarty catheter. An initial retrieval of clots was accomplished, with documentation by arteriography, instillation of urokinase (50,000 units) and clamping of vessel for 15 minutes. Subsequent passage of the Fogarty catheter and repeat urokinase infusion resulted in further retrieval of clots and improvement by repeat intraoperative arteriography. All interventions resulted in clinical restoration of perfusion to the affected limb. Six patients had amputations of the lower extremities (one transmetatarsal and one below the knee) during the 30 day postoperative period. Improvement in distal run-off was demonstrated by intraoperative arteriography and increases in the ankle to brachial ratio from 0.1 to 1.04, with a mean of 0.54, were noted. No complications from bleeding occurred. One patient died postoperatively because of myocardial infarction. Salvage of the limb may increase with combined embolectomy and thrombolytic therapy.

Lower extremity amputation: open versus closed.

Wound breakdown was assessed in 117 amputations for nonhealing lesions and peripheral vascular closure (chi 2 10.34). Nonhealing occurred in 10/63 amputations with primary skin closure when compared with those not closed (p less than .01). All 54 amputation sites treated by the open technique healed without revision. Of 22 toe amputations, the open technique performed in 14 patients required a mean of nine postoperative days; the closed-toe amputation technique performed in 8 patients needed a mean of 5.8 days; the closed-toe amputation requiring revision needed a mean of 36.3 days. Healing rates were significantly different when the wound was left open versus primarily closed (chi 2 8.56 p less than .01). Nineteen transmetatarsal amputations (TMA) were completed; 10 open TMAs required a mean of twenty-four days; 9 closed TMAs required a mean of fifteen days; and revision a mean of eighteen days. Of 51 below-the-knee amputations (BKA), 20 open BKAs required a mean of thirteen days; 3 closed BKAs required a mean of 18.5 days; and 1 revision required two hundred fifty-eight days postoperatively. Twenty-five above-the-knee amputations (AKA) were performed; the 10 open AKAs required a mean of sixteen days; the 15 closed AKAs required a mean of eleven days. There was no significant difference in healing rates of TMA, BKA, or AKA. Healing rates of toe amputations and amputation overall are, however, significantly different. Closed lower extremity amputation wounds require fewer hospital days than open, except if problems in wound healing require revision.

Subclavian-external carotid artery bypass graft. Restoring blood flow to the brain.

This article describes an unusual surgery for a type of carotid artery disease. The perioperative nurse has an important role on the vascular team when performing this procedure. For this reason, a thorough knowledge of the events and possible complications are important in the care of these patients. Careful preoperative nursing assessment and postoperative follow-up will help prevent any complications and promote a successful outcome in these patients.