History of the diagnosis and treatment of critical limb ischemia and diabetic foot.

The history of the recognition and surgical treatment of lower limb ischemia dates back to the Middle Ages. The twin Saints Comas and Damian were ascribed to have saved a gangrenous limb in the 13th century and became patrons of future surgeons. The physicians that followed developed the theories of blood flow, anatomy of the arterial circulation, and recognition that occlusive disease was the cause of limb ischemia and gangrene. Innovative physicians developed the techniques of arterial surgery and bypass grafting to restore limb blood flow and allow healing of lesions. In the 1960s, the era of endovascular intervention by the pioneering work of Charles Dotter, who developed techniques to image diseased arteries during a recanalization procedure. The development of guide wires, angioplasty balloons, and stents quickly followed. Management of lower limb ischemia and the diabetic foot will continue to evolve, building on the history and passion of preceding physicians and surgeons.

The path from art to evidence in treating critical limb ischaemia--reflections on 35 years' experience.

Despite numerous attempts, chronic critical limb ischaemia (CLI) has not been unequivocally defined as yet. Its epidemiology is poorly investigated and its prevalence probably higher than anticipated. It is accompanied by high mortality and morbidity irrespective of the way it is treated. Its management is very expensive. Additionally, the prevailing diabetes epidemic is increasing the need for revascularizations although there is a clear lack of evidence as to when to revascularize an ulcerated diabetic foot. The fast development of endovascular techniques blurs the vision as the window of opportunity for gathering proper evidence keeps narrowing. The notion of endovascular artistry prevails, but attempts to conduct proper studies with clear definitions, strict criteria and appropriate outcome measures in a standardised manner should continue--preferably using propensity scoring if randomised controlled trials are not possible. This review highlights some of the steps leading from art to evidence and illustrates the difficulties encountered along the path. In parallel with this overview, the progress of the treatment for CLI in Finland is described from the perspective of the work concluded at Helsinki University Central Hospital.

Historical reflections on the management of acute limb ischemia.

The history of clot removal consists primarily of efforts at procedures, techniques, and instruments that had suboptimal performance. In the 1960s, the amputation and death rates following attempts at removal were as high as 50%. A wide variety of instruments were used but none were specifically designed for embolus and thrombus removal. The need was obvious but the problem was unresolved.

The immersion foot syndrome. 1946.

1. Prolonged exposure of the extremities to cold insufficient to cause tissue freezing produces a well-defined syndrome. 'Immersion foot' is one of the descriptive but inaccurate terms applied to this syndrome. The clinical features, aetiology, pathology, prevention, and treatment of immersion foot are considered in detail. A discussion on pathogenesis is also included. 2. In the natural history of a typical case of immersion foot there are four stages: the period of exposure and the pre-hyperaemic, hyperaemic, and post-hyperaemic stages. 3. During exposure and immediately after rescue the feet are cold, numb, swollen, and pulseless. Intense vasoconstriction sufficient to arrest blood-flow is believed to be the predominant factor during this phase. 4. This is followed by a period of intense hyperaemia, increased swelling, and severe pain. Hyperaemia is due to the release in chilled and ischaemic tissues of relatively stable vasodilator metabolites; pain may be the result of relative anoxia of sensory nerve-endings. 5. Within 7-10 days of rescue the intense hyperaemia and swelling subside and pain diminishes in intensity. A lesser degree of hyperaemia may persist for several weeks. Objective disturbances of sensation and sweating and muscular atrophy and paralysis now become apparent. These findings are correlated with damage to the peripheral nerves. 6. After several weeks the feet become cold-sensitive; when exposed to low temperature they cool abnormally and may remain cold for several hours. Hyperhidrosis frequently accompanies this cold-sensitivity. The factors responsible for these phenomena are incompletely understood; several possible explanations are considered. 7. Severe cases may develop blisters and gangrene. The latter is usually superficial and massive loss of tissue is rare. 8. The hands may be affected but seldom as severely as the feet. The essential features of immersion hand are the same as those of immersion foot. 9. Prognosis depends upon severity. The extent of anaesthesia at 7-10 days has been found a useful guide to the latter, and has formed a basis of a method of classification. 10. Rapid warming of chilled tissues is condemned. Cold therapy is of value for the relief of pain in the hyperaemic stage, but should not be used in the pre-hyperaemic stage. Sympathectomy and other measures designed to increase the peripheral circulation should not be employed immediately after rescue, but may have a place in the treatment of the later cold-sensitive state. This paper records the results of observations made during 1941 and 1942. Delay in publication has been necessary because of war-time difficulties of maintaining contact between authors. In this respect we have received much help from Surgeon Rear-Admiral J. W. McNee. We wish to thank Professors R. S. Aitken and J. R. Learmonth for much helpful advice during the preparation of the paper. The charts have been prepared by the technical staff of the Wilkie Surgical Research Laboratory, University of Edinburgh. During the period of the study, one of us (R. L. R.) was in receipt of a personal grant from the Medical Research Council.

Chronic visceral ischemia.

The clinical syndrome of chronic intestinal ischemia has been examined through its evolution over the past century. Particular attention has been paid to the past 40 years and the contributions made by Dr Charles Rob. Although various diagnostic strategies have been introduced, the cornerstone of diagnosis remains the biplanar aortogram. Improvement in non-invasive imaging may allow us to understand the natural history of the disease via surveillance screening programs. Modern treatment, resulting in successful and durable reconstruction, consists of either anterograde bypass or transaortic endarterectomy. The future holds promise for the young investigator interested in solving the questions that persist concerning this unique vascular bed.

Dislipidemia e outros fatores de risco no acidente vascular cerebral iaquêmico / Dylslipidemia and other risk factors in ischaemic stroke

Neste trabalho o autor analisa os fatores de risco(FR) encontrados em 353 pacientes com acidente vascular isquêmico (AVCI). O FR encontrado com maior frequencia foi hipertensäo arterial sistêmica (HAS, 75,9 por cento), seguido por sedentarismo (49,3 por cento), tabagismo (48,2 por cento), etilismo (45,9 por cento), dislipidemia (42,3 por cento), obesidade (34 por cento), cardiopatia (30,3 por cento), diabetes mellitus (23,5 por cento ), entre outros. Em relaçäo a idade 81 por cento dos indivíduos tinham mais de 50 anos. Das dislipidemias encontramos níveis elevados do colesterol total em 23,7 por cento, do triglicerídio em 18,6 por cento, do colesterol LDL em 14,4 por cento e concentraçäo baixa do colesterol HDL em 9,3 por cento dos pacientes