Does an adjuvant AV-fistula improve the patency of a femorocrural PTFE bypass with distal vein cuff in critical leg ischaemia?--a prospective randomised multicentre trial.

INTRODUCTION: A lack of suitable veins can cause serious problems when attempting to revascularise critically ischaemic legs. Prosthetic grafts have much worse patency in the femocrural position, despite the use of distal anastomotic cuffs. The use of adjuvant AV-fistula at the distal anastomosis should increase the graft flow above the thrombotic threshold velocity and thus increase prosthetic graft patency. AIM: The aim of the study was to evaluate the benefit of an adjuvant AV-fistula on the patency of a femorocrural PTFE bypass with a distal vein cuff. MATERIALS AND METHODS: This prospective randomised multicentre trial was conducted in four centres. A total of 59 patients with critical leg ischaemia and no suitable veins for grafting were randomised to receive a femocrural PTFE bypass and distal vein cuff, with or without an adjuvant AV-fistula. Thirty-one patients were randomised to the AV-fistula group (AVFG) and 28 to the control group (CG). Six patients were lost to follow-up during the 2-year study time. RESULTS: There were six immediate occlusions in each treatment group, but half of these were saved by re-operation. The mean postoperative ankle-brachial index (ABI) was 0.85 in the AVFG and 0.94 in the CG. The primary and secondary patency rate at 2 years was 29 and 40% for the AVFG and 36 and 40% for the CG (NS). Leg salvage at 2 years was 65 and 68%, respectively (NS). CONCLUSION: Adjuvant AV-fistula does not improve the patency of a femorocrural PTFE bypass with a distal vein cuff.

Subacute primary Candida lung abscess.

A case of primary subacute Candida lung abscess is described. The most reliable way to diagnose a rare pulmonary disease is to perform an open lung biopsy. A review of the literature suggests that the diagnosis of a primary subacute abscess due to Candida albicans in vivo is unique.

Venoarteriolar response to experimental venous hypertension in legs with chronic venous insufficiency and in healthy legs, measured using a double-wavelength laser Doppler technique.

The venoarteriolar response (VAR) of the skin in legs caused by experimental venous hypertension was measured using a new, double-wavelength laser Doppler probe technique (543 nm and 780 nm). This enables the measurement of the laser Doppler flux in the superficial and deep layers of the skin simultaneously. The recordings were obtained from the leg with the patient in a recumbent position with a sphygmomanometer cuff around the thigh. The VAR was recorded at the cuff pressures of 30 mmHg and 60 mmHg. Ten patients with chronic venous insufficiency (CVI) and 20 control subjects with healthy legs were investigated. The VAR increased in relation to the increase of cuff pressure at both wavelengths. There were no significant differences in the VAR between the cuff pressures within or between the legs with CVI and healthy legs. The VAR measured at 780 nm was very significantly greater than the VAR measured at 543 nm in legs with CVI (p<0.005), as well as in healthy legs (p<0.001). The VAR depends both on the wavelength of the laser Doppler light used and on the degree of venous hypertension. The VAR is not impaired in legs with CVI compared with healthy legs.

Blood flux and venoarteriolar response of the skin in legs with chronic venous insufficiency measured at two different depths by using a double-wavelength laser Doppler technique.

The laser Doppler flux (LDF) and the venoarteriolar response (VAR) of the skin in legs with chronic venous insufficiency (CVI) was measured by using a new double-wavelength probe technique (543 nm and 780 nm). The recordings were taken in a recumbent and in a sitting position. Ten patients with CVI and 20 control subjects with healthy legs were investigated. The LDF was found to be significantly enhanced in a recumbent position at 543 nm and in a sitting position at 780 nm in legs with CVI compared with healthy legs (P<0.05 and P=0.02, respectively). The authors could not find the VAR to be impaired in either wavelength in legs with CVI compared with healthy legs. The double-wavelength probe technique makes it possible to record simultaneously the LDF in the superficial and deep layers of the skin on the same place in the leg.

Auditing a nationwide vascular registry--the 4-year Finnvasc experience. Finnvasc Study Group.

OBJECTIVE: To assess the validity of a national vascular registry. MATERIALS AND METHODS: 17,465 vascular and endovascular procedures, immediate reoperations excluded, registered in the Finnvasc registry from 26 centres during the years 1991-1994. CHIEF OUTCOME MEASURES: Comparison of the number of registered procedures with hospital records, comparison of initial registrations with a random sample of re-registration and comparison of the 1-year local data input of one major centre to the same data input of the central unit. RESULTS: The rate of missing registrations was 19% ranging from 0-47%. The data of the re-registered forms were in agreement with the original data in 93% of all data points, the range being from 81-100%. There was a difference of 1.5% in the data between the major centre and the central unit. CONCLUSIONS: The Finnvasc registry makes it possible to audit vascular surgery nationally, although a potential limitation is centres with low registration rates.

A multicentre comparison of once-daily subcutaneous dalteparin (low molecular weight heparin) and continuous intravenous heparin in the treatment of deep vein thrombosis.

OBJECTIVES: To compare the efficacy and safety of the low molecular weight heparin (LMWH) dalteparin with unfractionated heparin (UFH) in the acute treatment of DVT patients who had not previously received UFH. DESIGN: An open randomized multicentre trial with blinded analysis of venograms. SETTING: Seven hospitals in Sweden, Finland and the USA. SUBJECTS: A total of 330 patients, of 20 years or older, with suspected DVT, verified using venography. INTERVENTIONS: Fixed-dose dalteparin (200 IU kg-1) given as a once-daily subcutaneous injection, or aPTT adjusted i.v. UFH infusion for 6 to 10 days. MAIN OUTCOME MEASURES: Change in Marder score in patients with confirmed DVT and two evaluable venograms; PE, bleeding events and follow-up. RESULTS: Marder scores improved in 51% (95% CI 42-60%) of 92 patients treated with dalteparin and in 62% (95% CI 53-70%) of 98 patients treated with UFH (P = 0.152). One dalteparin-treated patient had a PE confirmed by V/Q scan; another had progressive thrombosis with swelling in the affected limb. Bleeding complications occurred in six patients in each group. One patient treated with dalteparin and five treated with UFH died during the 6-month follow-up period as a result of underlying malignancy or heart disease. The 6-month recurrence rate was low with both treatments (dalteparin, 3/97; UFH, 2/103). CONCLUSIONS: Fixed-dose subcutaneous dalteparin given once daily from the start of treatment is of equivalent efficacy and safety to conventional UFH therapy in the routine management of DVT.

Intravascular bronchioloalveolar tumor.

A 17-year-old girl was operated for a solitary well-circumscribed pulmonary parenchymal tumor and reoperated ten times for multiple recurrent similar pulmonary tumors during 24 years. Histologic examination revealed the so-called intravascular bronchioloalveolar tumor (IVBAT) in all instances. The patient died from pneumonia superimposed on decreased respiratory function 24 years after the onset of disease. This is the longest survival so far reported in IVBAT. The treatment was surgical in all phases of the disease, and the patient did not receive radiotherapy or cytostatic drug therapy. Mediastinal and pleural tumor nodules were removed 17 years from the first pulmonary operation, and 24 years after the first operation a fibrous tumor was removed from the retroperitoneal space. Immunohistologically, the tumor cells were positive for vimentin-type of intermediate filaments, in line with their mesenchymal nature. Endothelial markers, Factor VIII-related antigen and Ulex europaeus I lectin binding, were not found in convincingly neoplastic cells, and Schwann cell, epithelial cell, muscle cell, and histiocytic markers were absent. Thus, IVBAT appears to be a low-grade malignant mesenchymal neoplasm, composed of poorly differentiated mesenchymal cells, whose exact nature remains undefined with the currently used cell-type markers.

Stimulation threshold of myocardial electrodes in long-term cardiac pacing.

The stimulation threshold behaviour in long-term cardiac pacing is presented for a material of 45 myocardial electrodes. The initial stimulation threshold was measured in 25 cases and the mean value was 1.5 +/- 0.7 mA. The follow-up period was from 17 to 99 months (mean 50 months) and during that time 63 threshold measurements were made. The mean chronic stimulation threshold was 2.2 +/- 0.7 mA. It was not dependent on the aetiology or type of the conduction defect. There was no relationship between the initial and chronic stimulation threshold. In the region of the left ventricular apex, the chronic stimulation threshold was higher than in the anterior wall of the right ventricle. The long-term stimulation threshold was significantly higher in the cases of enlarged heart and in the age group less than or equal to 50 years than in those with a heart of normal size and in the age group greater than or equal to 70 years.

Oesophageal diverticula. A follow-up study of 34 patients.

Of the 34 patients treated surgically for oesophageal diverticula during a 17-year yperiod, 14 had Zenker's and 20 thoracic diverticula. In addition to three diverticular perforations, the selection of the patients for surgery was based on major symptomatology and roentgenological retention in the diverticulum. The most usual method was a simple diverticulectomy. One patient was lost because of an oesophagopleural fistula, while non-lethal complications occurred in 10 patients. Twenty-nine patients were available for the follow-up study, which was made, on an average, 5.5 years postoperatively. Four had died of other causes. Seventeen patients regarded the results as good and 11 as acceptable. A roentgenological recurrence was detected after six Zenker's and four thoracic diverticulectomies by using the hypotonic double contrast method. Most recurrences caused only minor symptoms, if any. Two new diverticula were found in addition to the recurrences. Only one patient was reoperated on, while the slight discomfort felt by the others was not considered an indication for surgery.