Sex-related differences of bone properties of pelvic limb and bone metabolism indices in 14-month-old ostriches (Struthio camelus).

1. Sex-related differences of long pelvic limb bones and serum bone metabolism indices were evaluated in 14-month-old female (N = 7) and male (N = 7) ostriches of similar body weights. 2. Densitometric parameters of femur, tibia and tarsometatarsus were determined using quantitative computed tomography (volumetric bone mineral density, calcium hydroxyapatite density and mean volumetric bone mineral density) and dual energy X-ray absorptiometry (bone mineral density and bone mineral content) methods. Geometrical parameters such as cortical bone area, cross-sectional area, second moment of inertia, mean relative wall thickness and cortical index were determined in the midshaft of bones. Mechanical properties of bones (maximum elastic strength and ultimate strength) were evaluated using three-point bending test. Serum concentrations of free amino acids, osteocalcin, N-terminal propeptide of type I procollagen, C-terminal telopeptides of type II collagen and total antioxidative capacity were also determined. 3. Bone weight and relative bone weight of all bones were significantly higher in males than in females. Significantly lower values of trabecular bone mineral density and calcium hydroxyapatite density were found in the trabecular bone of tibia in males. The highest number of the sex-related differences was observed in the tarsometatarsus where bone length, bone mineral content, cortical bone area, cross-sectional area and ultimate strength were higher in males. Serum concentrations of taurine, hydroxyproline, valine and isoleucine were significantly higher in males. 4. Higher loading of the tarsometatarsus in comparison to femur and tibia may be an important factor interacting with sex hormones in regulation of bone formation and mineralisation processes. Sex-related differences of bone properties were associated with increased serum concentration of selected amino acids in males.

Effects of increased stocking density and heat stress on growth, performance, carcase characteristics and skeletal properties in turkeys.

Effects of increased stocking density and heat stress on growth, feed conversion, carcase characteristics and skeletal system properties in turkeys were determined. One-day-old males (n=1674) were divided into two weight-matched groups exposed to different environmental conditions. Controls were reared at a stocking density of 2.8 birds/m(2) and at thermo-neutral temperature (TnT group), while the experimental group was exposed to heat-stress (HSID group) and reared at a stocking density of 3.4 birds/m(2) and ambient temperature increased by 5°C. At 28 days of age, 27 birds from each group were sacrificed, while at 126 days of age, 54 birds from each group were slaughtered. Increased stocking density and ambient temperature during the first four weeks of life increased the body weight (BW) of turkeys and weight, length, volume, vertical internal and horizontal external diameters of the tibia in the HSID group compared with the TnT group (P<0.05). In turkeys older than four weeks, increased stocking density and ambient temperature significantly decreased daily feed intake, final BW and relative weight of drumstick muscle by 4.7 per cent, 4.0 per cent and 3.3 per cent, respectively (P<0.05). The weight, length, volume, vertical and horizontal diameters, cross-sectional area, second moment of inertia, volumetric bone mineral density, maximum elastic strength and ultimate strength of bones were significantly lower in turkeys in the HSID group (P<0.05) at 126 days compared with turkeys in the TnT group at the same age. These results indicate that, up to four weeks of age, turkeys tolerate increased stocking density and heat stress better than birds between 5 and 18 weeks of age.

Anatomical classification of the shape and topography of the operated stomach.

The aim of the study was to present the classification of anatomical variants of the operated stomach, based on radiological and historical data. Different anatomical variants of the operated organ were found in 431 out of 2034 patients examined in the years 2006-2010. Four main groups were established: abnormal position along longitudinal (I) and horizontal axis (II), as well as abnormal shape (III) and stomach connections (IV). An additional group (V) encloses mixed forms that combine features of two or more of the main groups. The first group contains the partial and total translocation of the stomach into the thoracic cavity after the partial or total oesophagectomy. Depending on the applied surgical techniques used during the total oesophagectomy, the stomach could be located anteriorly or posteriorly to the pericardial sac. An elongated and gastrectatic form often with signs of pylorostenosis is visible in patients treated by vagotomy. The consequences of fundoplication included: lack of or narrow cardiac angle, and often a mild form of stomach cascade. The most common abnormal shape of the stomach was secondary to gastrectomy and gastric bending. The final organ shape depends on the type of applied surgical procedure that maintains physiological connection with the duodenum or an un-anatomical one, mostly with the jejunal loop. In banding, the body of the stomach forms an hourglass at the level of the artificial adjustable band, typically applied in surgical treatment of obesity (slim surgery).

Psoriasis and unreported excessive alcohol intake--a simple screening approach.

Psoriasis is a chronic immune-mediated skin disease of complex aetiology. Alcohol overuse has long been suspected to contribute to psoriasis pathology, and the knowledge of individual's drinking pattern may be of substantial importance for managing the disease. Unfortunately, a number of patients fail to admit to their true alcohol consumption and there is no single sign, symptom or laboratory parameter adequate for alcohol abuse diagnosis. However, there are some laboratory findings that, when present, should raise physician's suspicion that alcohol may be a problem. The aim of this article was to present simple, widely available and relatively reliable laboratory markers that might effectively assist physicians in establishing patient's drinking status. A possible screening approach is illustrated by two distinct reports of psoriatic patients who initially concealed having the problem with alcohol.

Effects of dietary calcium content and vitamin D source on skeletal properties in growing turkeys.

1. The aim of the study was to investigate the effects of feeding fast growing turkeys with differentiated dietary calcium (Ca) content, and the partial replacement of vitamin D(3) in the feed with 25-hydroxycholecalciferol (25(OH)D(3)), on skeletal properties. 2. One-day-old Big-6 male turkeys (n = 1008) were randomly divided into 4 groups, and two subgroups were created within each group. The groups were differentiated with 4 levels of Ca provision in the feed, namely 85% of the National Research Council (NRC) recommendation (Group Ca(1)); 95% as above (Group Ca(2)); 105% as above (Group Ca(3)); and 115% as above (Group Ca(4)). The first subgroup received the recommended dosage of cholecalciferol (vitamin D(3) subgroup) in the feed, while in the second subgroup (Hy-D subgroup), half of the dosage of cholecalciferol was replaced with 25(OH)D(3). At the ages of 4, 8, 12 and 20 weeks, 7 turkeys from each subgroup were randomly selected and killed to obtain the right tibia for densitometric, geometric and mechanical analyses. 3. This study showed advantageous effects of increased calcium supply in the diet on skeletal system properties, that were increased and produced the most desirable traits in turkeys receiving 95%, 105% and 115% of the NRC calcium recommendation. Benefits resulting from administration of 25(OH)D(3) in the diet were also obtained in the skeletal formation of turkeys, and the most advantageous effects were present in the group receiving 105% of recommended dietary Ca. 4. Effects on the metabolic response of the skeleton of turkeys to manipulation of dietary calcium content and vitamin D(3) source were the most evident in the groups between 4 and 12 weeks of life, and demonstrated a limited ability to induce a positive influence on bone properties at advanced stages of the production cycle by alteration of these dietary factors.

The long-term effect of alpha-ketoglutarate, given early in postnatal life, on both growth and various bone parameters in pigs.

The long-term effect of alpha-ketoglutarate (AKG) given for 21-24 days post-partum, on the skeleton of commercial pigs, was investigated. In experiment A, 12 pigs were given AKG [0.1 g/kg of body weight (b.w.) per day per os], while 12 controls were administered vehicle. At day 169, the left and right femur, humerus and sixth ribs were analysed for mechanical and geometrical properties and quantitative computed tomography. In experiment B, 32 piglets were divided equally into an AKG group (0.3 g/kg of b.w. per day) or a control group. Blood, taken at days 24 and 53 was analysed for plasma 17 beta-oestradiol. The main bone effect of AKG was to increase bone length in the sixth rib (7.3%, p < 0.01), ultimate strength (23%, p < 0.05), Young s modulus (52%, p < 0.001) and maximum elastic strength (31%, p = 0.056) compared with controls. In both experiments, AKG preferentially increased the growth of female piglets, whilst for male piglets AKG had the opposite effect. In addition, AKG elevated plasma 17 beta-oestradiol levels compared to those of controls at the end of the period of treatment (20%, p = 0.002). It is concluded that AKG has long-term effects on rib properties when given early in postnatal life whilst it elevates plasma 17 beta-oestradiol levels only so long as it is being administered.

Effects of alpha-ketoglutarate on bone homeostasis and plasma amino acids in turkeys.

The objective of the study was to evaluate the effect of denervation and alpha-ketoglutarate (AKG) administration on the development of osteopenia in the turkey radius. At 22 d of age, all turkeys were subjected to neurectomy of the right radius. Control turkeys were given a saline solution into the crop each day for 97 d. Experimental turkeys were given 0.4 g of AKG/kg of BW into the crop each day. After 98 d, BW was not affected by the AKG treatment. Volumetric bone mineral density of the radius was measured by quantitative computed tomography. Mechanical properties were tested using a 3-point bending test. Cross-sectional area, second moment of inertia, and mean relative wall thickness were measured as well. Amino acid concentrations were assessed with the use of ion-exchange chromatography. Denervation had a negative effect on all bone characteristics that were measured except bone length. The AKG had a positive effect on all bone characteristics except bone length. Plasma concentrations of proline and leucine were increased by AKG, whereas concentrations of taurine and glutamine were decreased. The turkey radius appears to be a good model for studying osteopenia because its development can be affected by treatments such as denervation and AKG administration.

Long-term denervation of the humerus in turkeys as an experimental model for osteopenia.

The aim of this study was to evaluate the influence of long-term denervation on volumetric bone mineral density, and geometrical and mechanical properties of the humerus in turkeys. The experiment was conducted from d 22 after hatching until wk 17 of life. All experimental birds (male turkeys) were randomly divided into 2 weight-matched groups. The first group of turkeys served as the control group and underwent a sham operation on the right wing, and the second group was subjected to surgical denervation of the right humerus. The denervation was performed by neurectomy of the radialis and the mediano-ulnaris nerves in the region of the proximal epiphysis of the humerus. All the left wings within both groups were surgically untouched. The left humerus served as the control bone to the right humerus in both investigated groups. Effect of denervation of humerus was determined in terms of geometrical and mechanical properties and quantitative computed tomography. The denervation of the humerus in turkeys significantly decreased volumetric bone mineral density, and geometrical and mechanical properties of this bone, when compared with the results obtained in humerus from the sham-operated or surgically untouched wings. However, no significant differences between right and left humerus were observed when analyzing all of the investigated parameters in the sham-operated group of turkeys. It is concluded that long-term denervation of humerus in turkeys induces osteopenia and may serve as a new experimental model for investigating factors that affect skeletal homeostasis in poultry and other vertebrates.

Myocardial revascularization before carotid endarterectomy.

Diffuse atherosclerosis involving more than 1 vascular bed is a challenging problem. The natural histories of carotid and coronary atherosclerosis are clearly intertwined. The optimal strategies for treatment of patients who present with carotid artery stenoses and co-existent coronary artery disease (CAD) remain controversial. Minimally invasive screening tests for CAD are often unreliable, and patients presenting with significant extracranial carotid artery stenoses should usually be assumed to harbor some degree of CAD. Numerous studies have confirmed, however, that in contrast to peripheral artery stenoses, hemodynamically significant stenoses of the coronary arteries are not necessarily the index lesions that produce myocardial infarctions (MIs). Although there are some anecdotal reports that myocardial revascularization prior to carotid endarterectomy (CEA) improves the short- and long-term cardiac outcomes of patients after CEA, no prospective, randomized, controlled studies have proven this hypothesis. Numerous adverse cardiac events can occur in the perioperative period including congestive heart failure (CHF), arrhythmias, unstable angina pectoris and both nonfatal and fatal MIs. Of these, only MIs are truly "hard" endpoints. The incidence of MI after CEA is much lower than after other commonly performed peripheral arterial operations such as aortic or infrainguinal procedures. The perioperative nonfatal and fatal MI rates after CEA average about 1.0% and 0.4%, respectively. The Coronary Artery Revascularization Prophylaxis (CARP) study is currently ongoing in the United States as a multicentered randomized prospective controlled trial sponsored by the Department of Veterans Affairs. In this study, patients with significant CAD who are undergoing operations for peripheral arterial disease are randomized to myocardial revascularization versus best medical care; however, CEA procedures are excluded from this study because cardiac morbidity is low. Based on the low incidence of adverse cardiac events in CEA patients, it is generally prudent to treat their CAD with best medical care rather than routine prophylactic myocardial revascularization.

How to avoid cardiac ischemic events associated with aortic surgery.

Whereas there is some degree of coronary artery disease (CAD) in most patients undergoing vascular surgery, there is no consensus regarding how to avoid perioperative cardiac ischemic events. Although this edition of Seminars in Vascular Surgery is devoted to aortic surgery, it must be remembered that the incidence of adverse cardiac outcomes after infrainguinal operations is at least as great as after aortic procedures. Thus, much of the information discussed herein will be applicable to patients undergoing all varieties of vascular surgery. Numerous strategies exist for preoperative cardiac testing before vascular operations. These strategies range from routine evaluation before surgery to a "minimalist" approach, treating all patients as though CAD was present. Although advocates of various algorithms often are unwavering in their convictions, there are no randomized, prospective studies comparing different strategies for evaluation and management of patients with CAD undergoing vascular surgery. Potential adverse effects of evaluation and cardiac intervention should be considered before undertaking screening studies. The authors analyzed the adverse outcomes of preoperative cardiac evaluation and intervention before vascular operations in patients treated at the Denver Department of Veterans Affairs Medical Center. Of 153 patients undergoing vascular procedures, 42 had extended cardiac evaluations. Sixteen (38%) patients had untoward events related to this evaluation. Extensive cardiac evaluation before vascular operations can result in morbidity, delays, and refusal to undergo vascular surgery. The underlying indication for vascular operations and the local iatrogenic cardiac complication rates should be considered before ordering special studies. Several recent randomized, prospective studies have established that perioperative beta-adrenergic blockade is beneficial in vascular patients with CAD. Beta-Blocker therapy can reduce the risk of perioperative adverse cardiac outcomes by 55%. The Coronary Artery Revascularization Prophylaxis (CARP) trial currently underway is a multicenter, prospective comparison of invasive intervention for CAD versus best medical care in patients undergoing aortic and lower extremity vascular surgery funded by the Department of Veterans Affairs Cooperative Studies Program.

[Localization of intraocular foreign bodies using computed tomography]. / Zastosowanie tomografii komputerowej (TK) w lokalizacji cial obcych wewnatrzgalkowych.

PURPOSE: To present the evaluation of computed tomography (CT) application for detecting the intraocular foreign bodies. MATERIAL AND METHODS: Sixteen computed tomographies of orbit to localise a foreign body were performed in the 2nd Radiology Department at Lublin University School of Medicine from May 1995 to October 1998. During examination 2 mm computed tomography cuts were taken. In almost all cases fundus examination was not possible because of hazy media (cataract, vitreous haemorrhage, endophthalmitis). Pars plana vitrectomy was applied to remove foreign body in all cases. RESULTS: In 14 cases a foreign body was localised inside the eye (3 of them were embedded in the wall of the eye) and in 2 cases a double perforation was noticed. With pars plana vitrectomy 12 of 14 intraocular foreign bodies were removed. Two foreign bodies deeply embedded in the wall of the eye were left. One of the two foreign bodies after double perforation was removed from the orbit and the second, which was localized deeply in the orbit, was left. CONCLUSION: The localisation of the foreign bodies using the computed tomography is a very accurate and sensitive method, facilitating further surgery.

Iatrogenic vascular injuries from percutaneous vascular suturing devices.

OBJECTIVE: The purpose of this study was to examine the patterns of injury and the strategies of surgical repair of iatrogenic vascular injuries from a percutaneous vascular suturing device after arterial cannulation. METHODS: We retrospectively reviewed the clinical experience from an academic vascular surgical practice over a 2-year period. The subjects were patients undergoing vascular repair of iatrogenic vascular injury after deployment of a percutaneous vascular suturing device. Interventions were direct repair of arterial injury (with or without device extraction) or arterial thrombectomy and repair. The main outcome variables included patterns of arterial injury, magnitude of arterial repair, limb salvage, hospital stay, and perioperative mortality and morbidity rates. RESULTS: From August 1998 through August 2000, eight patients (4 men, 4 women; median age, 55 years; range, 44-80 years) required vascular operations for complications of percutaneous suturing devices after diagnostic (2) or therapeutic (6) arteriograms through a transfemoral approach. Complications included four pseudoaneurysms (1 infected) due to arterial tear from suture pull through, two entrapped closure devices due to device malfunction, and two arterial thromboses due to narrowing/severe intimal dissection. All patients required operative intervention. Direct suture repair with or without device removal was performed in five patients, arterial debridement with vein patch angioplasty in one patient, and arterial thrombectomy and vein patch angioplasty in two patients. There were no perioperative deaths. The median hospital stay was 5 days (range, 2-33). Limbs were salvaged in all patients with a mean follow-up of 4.8 months (range, 1-13). CONCLUSIONS: Although abbreviated postangiography recovery periods and early ambulation have motivated the widespread use of percutaneous suturing devices, the infrequent occurrence of vascular injuries produced by these devices can be significantly more challenging than simple acute pseudoaneurysms or hemorrhage. In addition, thrombotic complications have a small but finite risk of limb loss.

Epithelioid hemangioendothelioma of the common femoral vein: Case report and review of the literature.

A young competitive skier had venous claudication. A stenosis of the left common femoral vein was revealed by means of an examination. Exploration and vein patch angioplasty were performed, and because of both the unusual appearance (focal thickening of vein wall) and the unclear etiology of the lesion, frozen and permanent sections of the wall were obtained. Epithelioid hemangioendothelioma, a rare intravascular sarcoma, was revealed by means of an examination of the permanent sections. Two additional procedures were required to completely excise the epithelioid hemangioendothelioma. We discuss these rare vascular malignancies and include a review of the available literature. Also, oncologic principles important in both the diagnosis and therapy of intravascular sarcomas are discussed.

HRCT examinations in the course of silicosis.

Evaluation of diagnostic possibilities of high definition computerized tomography was performed on the material of 38 patients with recognized silicosis of small opacities on the bases of long lasting exposition, clinical and radiographic picture. Special usefulness of HRCT was shown in revealing early, scanty, radiographically imperceptible nodular changes. The presence of the so-called air traps was shown on expiratory sections.

The use of USG spatial reconstructions in diagnosing cholelithiasis and cholecystitis.

The aim of the paper is to determine diagnostic value of Spatial USG reconstructions in the diagnostics of cholelithiasis and inflammatory changes in the gallbladder. There was discussed the optimal way of examining the gallbladder in 3D USG presentation and advantages resulting from the use of the spatial option in diagnosing biliary deposits in selected inflammatory changes. USG spatial reconstructions which supplement the standard 2D USG examination in the diagnostics of difficult and doubtful cases of gallbladder pathology were found useful.

Possibilities of spatial imaging of carotid arteries pathologies in Power-Doppler US.

The aim of the study was to assess the value of Power-Doppler US spatial reconstructions in examining pathologies of carotid arteries for determining its role in the diagnostic algorithm. 3D Power-Doppler US reconstructions were performed in 19 patients with pathologies of carotid arteries qualified for surgical treatment on the basis of Color-Doppler examinations. Digital data of 2D US sections secondarily gave spatial pictures. Most frequently, 14 times, different degrees of carotid artery stenosis were found, in 3 cases critical, and complete impatency was observed twice. The narrowings were caused by both atheromas and parietal clots. In 3 cases the internal carotid artery formed an angular refraction. Spatial pictures also determined the geometry of division of common carotid arteries. It was found that Power-Doppler 3D US perspectively visualizes the configuration of carotid vessels and the range of their pathology facilitating understanding of the extent of changes and mutual topographic relationships. Spatial imaging let visualize atheromas and ulcerations of their surfaces besides the degree of carotid arteries narrowing.

Diagnostic value of US and CT in the assessment of ovarian teratomas and their qualifications for surgical treatment with laparoscopic method.

In the group of 17 women after surgery with histopathologically confirmed diagnosis of teratomas diagnostic usefulness of US and CT was analysed. Differentiated echostructure of tumours was correlated with different densities of pathologic tissues in CT examination, also after their contrast enhancement. In 2 patients teratomas of both ovaries were recognised, in the remaining 15 women tumours were unilateral. In total morphologic pictures of 19 teratomas were assessed, 9 times tumours with prevailing liquid component had the picture of a thick-walled cyst, 7 times these were hyperechogenic fatty foci and in 3 cases had the character of solid tumours. Teratomas had different morphologic pictures, but it was possible to show the prevalence of one element and classify the tumour to one of the three types of teratomas. It was found that US examination, due to its high frequency, lets early diagnose teratomas before they are accessible in the clinical exam, in the symptomless period or when they give indirect symptoms, usually dysuric ones. CT examination, due to its high sensitivity in recognising fatty tissue and calcifications, is necessary before laparoscopic operation requiring fragmentation of big tumours to determine their character.

Cost for inpatient care of venous thrombosis: a trial of enoxaparin vs standard heparin.

BACKGROUND: Enoxaparin, a low-molecular-weight heparin administered to hospitalized patients once or twice daily, has shown efficacy and safety equivalent to unfractionated heparin in the treatment of acute venous thromboembolic disease. Although the cost of either enoxaparin regimen is greater than that of unfractionated heparin, the overall cost of care for each of these 3 treatment strategies is unknown. METHODS: A cost minimization analysis of a 3-month, partially blinded, randomized, controlled efficacy and safety trial of anticoagulant therapy for deep vein thrombosis. Three hundred thirty-nine hospitalized patients with symptomatic lower extremity deep vein thrombosis were randomly assigned to initial therapy with subcutaneous enoxaparin either once (n = 112) or twice (n = 123) daily, or with dose-adjusted intravenous unfractionated heparin (n = 104), followed by long-term oral anticoagulant therapy. Estimated 1997 total cost from a third-party payer perspective for the 3-month episode of care was calculated by assigning standard unit costs to counts of medical resources used by each patient in the clinical trial. RESULTS: Average total cost for the 3-month episode of care was similar across all 3 treatment regimens: once-daily dose of enoxaparin, $12,166 (95% confidence interval [CI], $10,744-$13,588); twice-daily dose of enoxaparin, $11,558 (95% CI, $10,201-$12,915); and unfractionated heparin, $12,146 (95% CI, $10,670-$12,622). Bootstrapped estimates and sensitivity analyses did not significantly change findings. CONCLUSIONS: There was no significant difference in the overall cost for the 3-month episode of care for patients treated with either enoxaparin or unfractionated heparin. Additional acquisition costs for anticoagulant medication among patients treated with enoxaparin were offset by savings associated with lower incidence of hospital readmission and shorter duration of venous thromboembolism-related readmissions.

Yield of repeated screening for abdominal aortic aneurysm after a 4-year interval. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators.

BACKGROUND: Little is known about the rate at which new abdominal aortic aneurysms (AAAs) develop or whether screening older men for AAA, if undertaken, should be limited to once in a lifetime or repeated at intervals. METHODS: A large population of veterans, aged 50 through 79 years, completed a questionnaire and underwent ultrasound screening for AAA. Of these, 5151 without AAA on the initial ultrasound (defined as infrarenal aortic diameter of 3.0 cm or larger) were selected randomly to be invited for a second ultrasound screening after an interval of 4 years. Local records and national databases were searched to identify deaths and AAA diagnoses made during the study interval in subjects who did not attend the rescreening. RESULTS: Of the 5151 subjects selected for a second screening, 598 (11.6%) had died (none due to AAA), and 20 (0.4%) had an interim diagnosis of AAA. A second screening was performed on 2622 (50.9%), of whom 58 (2.2%; 95% confidence interval, 1.6%-2.8%) had new AAA. Three new AAAs were 4.0 to 4.9 cm, 10 were 3.5 to 3.9 cm, and 45 were 3.0 to 3.4 cm. Independent predictors of new AAA at the second screening included current smoker (odds ratio, 3.09; 95% confidence, 1.74-5.50), coronary artery disease (odds ratio, 1.81; 95% confidence interval, 1.07-3.07), and, in a separate model using a composite variable, any atherosclerosis (odds ratio, 1.97; 95% confidence interval, 1.16-3.35). Adding the interim and rescreening diagnosis rates suggests a 4-year incidence rate of 2.6%. Rescreening only in subjects with infrarenal aortic diameter of 2.5 cm or greater on the initial ultrasound would have missed more than two thirds of the new AAAs. CONCLUSIONS: A second screening is of little practical value after 4 years, mainly because the AAAs detected are small. However, the incidence that we observed suggests that a second screening after longer intervals (ie, more than 8 years) may provide yields similar to those seen in initial screening and therefore warrants further study.

Negative impact of cardiac evaluation before vascular surgery.

The optimal preoperative evaluation of cardiac risk in patients with peripheral vascular disease is controversial. In developing a paradigm for preoperative cardiac workup, potential adverse effects of evaluation and cardiac intervention must be considered. This study analyzed the deleterious outcomes of extensive, comprehensive cardiac evaluation and intervention before planned vascular surgery in patients treated at the Denver Department of Veterans Affairs Medical Center. Over a 12-month period between 1994 and 1995, 161 patients were scheduled to undergo major vascular operations; 153 patients came to operation. The decision to pursue a cardiac evaluation was variously made by a combination of surgeons, cardiologists, and anesthesiologists. No defined protocol was followed. Cardiac history, chest X-rays and ECGs were obtained for all patients. Extended cardiac evaluation included these studies plus special tests, including echocardiography (echo), radionuclide ventriculography (RNVG), dipyridamole thallium scintigraphy (DTS), and cardiac catheterization (CC). Extended cardiac evaluations were undertaken in 42 patients. Complications related to percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) were also recorded. Cardiac mortality and morbidity after vascular interventions were itemized in all 153 patients. Forty-two male patients, aged 68 +/- 9 years, underwent extended cardiac evaluations before planned vascular operations. The median elapsed time for cardiac workup was 14 days (mean 30 +/- 59 days). The median and mean times from cardiac workup to vascular surgery were 25 days and 76 +/- 142 days, respectively. Eighteen (43%) patients had echo or RNVG; 22 (52%) patients had DTS; 27 (64%) had CC; 9 (21%) had PTCA; 7 (17%) had CABG. Sixteen (38%) patients had untoward events related to cardiac evaluation. Eight patients (19%: one with cerebrovascular disease, and seven with aortic aneurysms) refused vascular surgery after extended cardiac workup. Complications attributable to CC, PTCA, and CABG included prosthetic graft infection, pseudoaneurysms (two), sternal wound infections (two), renal failure and brain anoxia. Two patients with severe limb ischemia who were candidates for revascularization ultimately required amputations because of delay due to cardiac evaluations. Extensive cardiac evaluation prior to vascular operations can result in morbidity, delays, and refusal to undergo vascular surgery. The underlying indication for vascular operations and the local iatrogenic cardiac complication rates must be considered before ordering special studies.