Haemodynamic results of femoropopliteal percutaneous transluminal angioplasty.

OBJECTIVES: To determine the utility of percutaneous transluminal angioplasty (PTA) of the femoropopliteal segment in patients with claudication and critical leg ischaemia (CLI). DESIGN: Longitudinal observational study. SETTING: A university based vascular surgical centre. MATERIAL: Ninety-five patients with stenosing or occlusive arterial lesions of the femoropopliteal segment underwent 52 primary PTA for claudication and 50 primary PTA for CLI. METHODS: The procedure was considered haemodynamically successful when the increase of immediate postprocedural ABI was 0.15 or more. The criterion for haemodynamic success during follow-up was an ABI having not decreased by more than 0.15 from the immediate postprocedural level. The run-off arteries were graded according to the scoring system proposed by the SVS/ISCVS. RESULTS: Among the technically successful procedures (83%), the haemodynamic success rate was 77% at 1 month, 55% after 1 year, and 51% after 2 years. The cumulative haemodynamic success rates were 83%, 66% and 61% in claudicants, and 70%, 42%, and 38% in CLI (p = 0.03). In patients with a run-off score < or = 7.5, the success rates were 84%, 67%, and 60%, respectively, whereas in those with a crural score > 7.5 these were 61%, 39%, and 39%, respectively (p = 0.04). CONCLUSIONS: The haemodynamic results suggest that PTA to the femoropopliteal segment is seldom a procedure of choice for critically ischaemic legs with poor run-off. The run-off score is useful in identifying patients who may benefit from PTA.

The utility of duplex scanning in infrainguinal vein graft surveillance: results from a randomised controlled study.

OBJECTIVES: To evaluate the utility and efficacy of colour-coded duplex scanning as an adjunct to clinical surveillance of infrainguinal vein bypass surgery. DESIGN: Prospective controlled randomised trial. METHODS: The trial included 179 consecutive patients undergoing 185 primary infrainguinal vein graft reconstructions during a 3-year period. Patients alive without amputation and with open graft at 1 month were randomised to a surveillance program based on clinical examination and ankle-brachial pressure index measurement (ABI group) or additional duplex scanning (DD group). All patients were scheduled for surveillance at 1, 3, 6, 9 and 12 months after operation. RESULTS: Surveillance identified four failing grafts in the ABI group and 11 in the DD group which were revised. The number of occluded grafts was seven in ABI group and 12 in DD group. At 1-year overall cumulative assisted primary patency rates in the ABI group and in the DD group were 74% and 65% respectively (p = 0.21), corresponding secondary patency rates were 84% and 71% (p = 0.04) and limb salvage rates 88% versus 81% (p = 0.23) respectively. CONCLUSIONS: This study failed to show any beneficial effect of duplex scanning in a surveillance program, which was difficult to accomplish as a part of routine clinical work. However, the main difference in outcome appeared during the first postoperative month before the commencement of the surveillance program.

Endoscopically inserted stent as treatment for pancreatic ascites. A case report.

After 3 weeks of unsuccessful conservative treatment, a pancreatic fistula with peritoneal fluid collection was managed with the endoscopic insertion of a stent from the duodenum into the pancreatic duct beyond the origin of the fistula. The patient who presented contraindications at surgery, made a remarkable recovery. At stent-retrieval, however, a stricture formation was seen in the main pancreatic duct.

How to estimate the size of the donor liver.

Of readily available methods to estimate the donor liver size, measurement of the body circumference at the xiphoid level (xiphoid measure) appeared to be the most accurate in the present prospective study of 60 donors and 57 recipients (r = 0.64, P = 0.0001). The estimated liver volume could be calculated using the equation: bloodless liver volume (1) = 1.44 x xiphoid measure (m). The difference between donor and recipient xiphoid measures was significantly higher in slowly recovering patients than in those recovering uneventfully (7 +/- 7 cm vs. - 5 +/- 8 cm, P < 0.001). The bloodless donor liver volume measured by water displacement averaged 1249 +/- 230 ml and had increased by 3 weeks posttransplant by 64 +/- 28% as determined using computed tomography. The volume of the liver graft seemed to adapt to the recipient as it correlated positively with body weight (r = 0.64, P < 0.01) and negatively with the age of the recipient (r = -0.42, P < 0.01). The liver graft volume seemed to increase less markedly in patients with a slow recovery than in those with an uncomplicated recovery (37% +/- 15% vs. 68% +/- 24%, P < 0.001). We conclude that a simple measurement of the body circumference at the xiphoid level can be used to estimate the donor liver volume. A gross mismatch of this parameter between the donor and the recipient seems to increase the risk of graft dysfunction. We also found that the change in the liver graft volume is influenced by the recipient's age and body weight.

Blood flow in free muscle flaps measured by color Doppler ultrasonography.

Color Doppler ultrasonography, a noninvasive method for studying changes in blood flow, has been used to monitor 18 patients with free microvascular lower limb muscle flaps. The peak, mean, and minimum velocities, resistance indices, and diameters of the flap pedicle arteries and also of the limb recipient arteries proximal to the microvascular anastomoses were measured at 2 and 6 weeks and 3, 6, and 9 months after surgery. The peak velocities did not significantly differ from each other, but the mean velocity in the flap pedicle arteries was 12.5% higher than that in the recipient arteries throughout the study period. End diastolic velocity in the pedicle was positive (toward the ultrasound probe) at 2 weeks (mean, 2 cm/sec, SD 10), 6 weeks (mean, 5 cm/sec, SD 16), and 3 months (mean, 3 cm/sec, SD 13) after surgery and significantly higher (P < 0.05) than at 6 months (mean, 7 cm/sec, SD 11), when the pattern of blood flow was normal forward/backward flow during systole/diastole. The resistance indices of the pedicle at 2 weeks (Ri = 0.978), 6 weeks (Ri = 0.936), and 3 months (Ri = 1.001) were significantly lower (P < 0.05) than at 6 months (Ri = 1.108), when the pedicle and recipient artery indices were the same. The diameter of the pedicle arteries was 14% smaller than those of the recipient arteries, but did not change during follow-up. This prospective clinical study shows that blood flow in the pedicle of a free microvascular muscle flap is increased until 6 months after surgery, mainly due to the increased minimum velocity of the pedicle in diastole and decreased resistance index. These findings can be attributed to the loss of vessel tone after denervation and are in accordance with earlier studies showing that denervated muscles lose their autoregulation and that blood flow increases, but that these phenomena subside with time. Increased blood flow in free muscle flaps can explain the high success rate of microanastomoses and positive effect on wound healing.

Thrombolytic treatment of acute on chronic leg ischaemia.

The efficacy of thrombolysis was retrospectively studied in patients with acute on chronic ischaemia in the lower extremity. A total number of 68 thrombolytic treatments were given to 65 patients, 58 (85%) because of native arterial occlusions and 10 (15%) because of occluded grafts. Tissue plasminogen activator was the lytic agent used in all patients. In native arteries, thrombolysis alone was successful in 15 (52%) out of 29 legs, whereas 22 (85%) out of 26 thrombolyses followed by angioplasty or surgery were effective. Thrombolysis alone was successful in two and failed in five out of 10 occluded grafts. Patency was achieved by combination with surgery in the other three cases. Twelve-month patency was 34% after thrombolysis alone and 69% (P < 0.05) when combined with surgery or angioplasty. The 30-day mortality rate was 9%. Thrombolysis can be used alone in acute on chronic ischaemia in the lower extremities. The immediate and the long-term results are clearly improved when thrombolysis is combined with angioplasty or reconstructive surgery to treat the underlying cause.

Late biliary stenosis after conservative management of traumatic liver rupture: case report.

An extensive liver rupture developed in a 50-year-old woman after she received severe blunt injuries in a criminal assault. Nonsurgical management of the liver injury led to recovery of the patient despite a serious blood loss and multiorgan failure. However, 3 months after the injury a complete left bile duct stenosis with liver dysfunction and two hepatic artery pseudoaneurysms were found. Biliodigestive bypass restored normal liver function.

Spontaneous perforation of the rectum by carcinoma of the prostate. Case report.

A case of spontaneous perforation of the rectum by a locally advanced prostatic carcinoma is described. The mechanisms of rectal involvement by prostatic carcinoma are discussed, focusing attention on the difficulties in differential diagnosis with primary carcinoma of the rectum.

Magnetization transfer imaging of the abdomen at 0.1 T: detection of hepatic neoplasms.

Magnetization transfer (MT) techniques have been proposed as a method of increasing contrast in MR images. To evaluate the feasibility of MT imaging of the abdomen at 0.1 T and to assess the clinical utility of this technique, the authors studied tissue contrast with a gradient-echo pulse sequence and an MT sequence in four normal volunteers, and in 17 patients with known primary or secondary neoplasms of the liver. The MT technique increased contrast between the liver and other tissues such as spleen, skeletal muscle and subcutaneous fat. The technique also produced increased contrast between hepatic tumors and normal liver parenchyma in gradient-echo images.

Prophylactic minitracheostomy after thoracotomy: a prospective, random control, clinical trial.

The effect of prophylactic minitracheostomy on the incidence of postoperative atelectasis and pulmonary gas exchange was evaluated in a prospective, random control study of 29 patients undergoing thoracotomy. Fourteen were randomly allocated to have a minitracheostomy, which was done in the recovery room immediately after operation, and the remainder acted as controls. Increased radiodensity and atelectasis were seen more often on the chest radiographs of the control patients on the first (p less than 0.05) and on the seventh postoperative days (p less than 0.01), irrespective of the extent of the pulmonary operation. Bronchial lavage under general anaesthesia or sedation was required by 6 of the 15 control patients, but by none of those who had had a minitracheostomy (p less than 0.05). These results support the hypothesis that minitracheostomy is a useful adjunct to postoperative care after thoracotomy.

Ultrasound guidance for pericardiocentesis.

Sonographic guidance with 41 punctures and 38 catheterizations was employed in 68 patients. The approach was either intercostal or subxiphoid. Most punctures were performed with a 1.4-mm-thick plastic-sheathed cannula after local anesthesia. Complications were observed in 7 patients. In one patient a catheter introduced with a movable core-type guidewire pierced the right ventricle wall with uneventful recovery after surgery. Intercostal drainage caused pleural pain in 2 patients, and in 2, leakage to the pleural space. Two patients with heart transplants had severe bradycardia and drop of blood pressure, one after needle drainage and the other during guidewire manipulation. Direct monitoring generally ensures a correct position of the instruments and hazards to adjacent organs can be avoided. In small effusions a simple needle aspiration with a plastic-sheathed cannula is safer than catheter drainage.

Intraoperative ultrasound as an aid to surgical strategy in liver tumor.

Ultrasonography of the liver was performed on 27 patients during laparotomy for liver lesions--11 primary and 13 metastatic mainly colon/rectum malignancies, and three benign conditions. Supplementary information on the liver parenchyma was provided in 11 cases (41%) in which the surgical strategy was decided simply by inspection and palpation of the liver. Ultrasound was most valuable for visualizing the vascular anatomy of the liver, giving clarification in 18 cases (66%), especially the relationship of tumor to portal and hepatic veins. This was decisive for the surgical strategy in four cases, enabling resection in two and modifying planned procedure in two. In a case of polycystic liver, ultrasonography imaged deep-lying cysts and aided the fenestration procedure. Liver resection was performed in 16 cases without operative mortality. Hepatic ultrasonography is useful for determining tumor spread, but of even greater value for the determination of strategy by clarifying tumor/vascular anatomic relationships.

Crossed fused ectopy of the right kidney complicating the repair of abdominal aortic aneurysm.

A case with crossed fused ectopy of the right kidney covering an abdominal aortic aneurysm and thus complicating its repair is described as a rarity.

Omnipaque and Gastrografin in gastrointestinal follow-through examinations.

The non-ionic low-osmolar contrast medium Omnipaque was compared with the conventional ionic high-osmolar contrast medium Gastrografin in a randomized, double blind study comprising 71 consecutive gastrointestinal follow-through examinations performed because of suspected ileus or anastomosis control. The patients' reaction were confined to nausea, emesis and diarrhoe being very similar in both groups and related to the patients' illnesses. The taste of Gastrografin was more often judged unpleasant, but the difference was not significant. Omniplaque scored significantly better for contrast medium density and diagnostic visualisation in the small bowel, otherwise the differences were negligible. There were no significant differences in the transit time into the caecum. The high price of Omnipaque restricts its routine use. It may be diagnostically indicated in selected cases where greater accuracy in the delineation of pathologic anatomical details in the small bowel is desired.

Results and complications of percutaneous nephrostomy.

A series of 181 patients (158 with obstructive uropathy) treated by percutaneous nephrostomy (PN) in 1978-1987 is evaluated. In 8.3% of the patients PN did not succeed. The success rate of PN was lower when done outside normal working hours and before ultrasound guidance was used. Major complications occurred in 5.5% and minor ones in 10.5%. There was no direct mortality. The complications and the possible avoidance of them are discussed. In 68% of patients nephrostomy improved their clinical condition. The benefit of PN was closely related to the existing renal recovery potential following the relief of obstruction; a problem that has not yet been fully solved.

Aspiration biopsy of the spleen in patients with sarcoidosis.

Fine-needle aspiration biopsy of the spleen was performed on 101 patients with suggested sarcoidosis; it was the final diagnosis in 79. Adequate specimens were obtained in all cases with a 0.8 X 80 mm or 0.7 X 40 mm disposable needle. Fine-needle biopsy specimens of the spleen showed a granulomatous reaction in 19 out of the 79 cases with sarcoidosis (24%). There were three minor biopsy complications that required no treatment.

Ultrasonically guided fine-needle aspiration biopsy in focal pancreatic lesions.

Ultrasonically guided fine-needle aspiration biopsy was performed in 100 patients with a focal pancreatic lesion. The lesion was a well-defined solid mass of 1 to 4 cm in 37 cases, a well-defined solid mass of 4.5 to 10 cm in 28 cases, an intrapancreatic cystic lesion in 23 cases, and an ill-defined prominent area in 12 cases. The samples were taken with a one-hand instrument and 0.7 to 0.9 mm disposable needles without a puncture adaptor. The material was sufficient for cytologic analysis in 98 cases. Malignant cells were obtained in 44 of the 49 cases with pancreatic carcinoma and lymphoma cells in one case with lymphomatous infiltration. Four of the six cases of cystadenoma could be identified cytologically. In solid inflammatory lesions, the nature of the lesion was seen in 12 of the 17 cases. There were no false positive reports of malignancy. The solid prominent areas of normal pancreatic tissue yielded normal cytologic samples. Aspirates of cystic lesions in the pancreas revealed one malignant case, and infected lesions could be differentiated from non-infected in the rest. There was one complication in a patient with an obstructed and dilated common bile duct. The aspiration procedure caused severe pain and the operation was performed earlier than scheduled. Diagnostic material is obtained in the majority of ultrasound guided aspiration biopsies of the pancreas. In malignancy, false negative results occur in about 10 per cent of cases.