Lower extremity arterial occlusive disease.

The clinician must first understand the natural history of chronic lower extremity ischemia before making a decision regarding therapeutic options. Clearly, mild ischemia as evidenced by claudication does not place the patient at significant risk for limb loss. Initial conservative treatment emphasizing abstinence from tobacco products, control of underlying medical maladies, and an exercise program, along with patient reassurance, will adequately treat the majority of claudicators. When ischemia is present, patient education regarding foot care and avoidance of trauma are beneficial. Limb-threatening ischemia often requires revascularization. Adequate preoperative cardiologic evaluation and intraoperative monitoring have greatly reduced the morbidity and mortality of arterial reconstruction. Selection of the appropriate recipient vessel and bypass conduit enables limb salvage, whereas amputation would have been performed just a few years ago. Continued analysis of treatment outcomes will further define appropriate intervention in the future.

Utility of arteriography in penetrating extremity injuries.

The role of contrast arteriography in the management of patients with penetrating injuries of the extremities is a subject of active debate. To examine our experience, the charts of patients with penetrating injuries of the extremities were retrospectively reviewed. Data from 82 consecutive patients with 98 wounds over the 5-year period from January 1984 to December 1988 were reviewed. Sixty-five arteriograms were obtained to investigate 98 wounds: 8 to localize a clinically apparent wound and 57 because of proximity of the wound or the trajectory of the injuring agent to a major neurovascular bundle. Of the 57 arteriograms obtained because of proximity, 11 identified a vascular injury (19%). Six of these wounds required vascular repair; five patients were treated expectantly. Six of the eight arteriograms obtained for clinical indications were positive (75%), while two were negative (25%). There were no amputations in the study, and all vascular reconstructions were considered successful by clinical and vascular laboratory criteria. One patient died of thoracic injuries; otherwise, all patients were discharged in good condition. Long-term follow-up was not available. In summary, 19% of arteriograms done because of proximity criteria alone identified a clinically occult vascular injury. While only 11% of all proximity arteriograms revealed injuries requiring surgical repair, this rate of significant injury warrants aggressive use of proximity arteriography in a patient population that is prone to poor follow-up.

Risk factors for gallbladder perforation.

Perforation of the gallbladder is a potentially lethal problem due in part to a delay in diagnosis. In an effort to improve our management of these patients, we reviewed all patients seen at the UCLA affiliated hospitals between 1955 and 1983 who had perforation of the gallbladder. Fifty-one patients were reviewed and perforations categorized as either acute (type I) in 16 (31%), subacute (type II) in 20 (39%), or chronic (type III) in 15 (29%). A history suggestive of chronic gallstone disease was obtained in 0% of patients with type I, in 35% of patients with type II, and 60% of patients with type III perforations. The incidence of severe systemic diseases was significantly greater (p less than 0.01) in patients with type I as compared to type III perforation. Based on these data, clinical profiles have been developed for patients at risk of developing acute versus chronic gallbladder perforation. Awareness of these groupings forms the basis for early recognition and treatment of acute gallbladder perforation.