The ulcerated leg: when to revascularize.

The role of peripheral arterial disease in ulcerated diabetic feet has long been underestimated. Progressive claudication, rest pain and the extent of irreversible tissue loss have frequently been indications for revascularization for neuroischaemic ulcers in diabetic patients. These typical ischaemic symptoms are warning signs that are less frequent in diabetic individuals with ischaemia than those without diabetes. Consequently, 30-50% of individuals with diabetes and foot ulcers already have gangrene at admission and are therefore often considered unsuitable for revascularization. Furthermore, the healing of a neuroischaemic ulcer is worsened by microvascular dysfunction, causing arteriovenous shunting, capillary ischaemia, leakage and venous pooling. Therefore, the threshold of revascularizing neuroischaemic ulcers should be lower than that of purely ischaemic ulcers. Comorbidity, ulcer characteristics and infection affect the decision as to when to intervene, as do the severity and extent of occlusive arterial lesions. The window of opportunity for vascular intervention in the neuroischaemic diabetic foot should not be missed, and the need for early vascular intervention as an integrated part of a strategy to achieve healing should be emphasized. Noninvasive vascular testing should be performed on all individuals with an ulcerated diabetic foot. The arterial tree should be imaged if noninvasive tests indicate ischaemia or when mild or questionable ischaemia is diagnosed and conservative treatment does not promote ulcer healing in 6 weeks. Revascularization should be performed whenever feasible to repair distal perfusion to achieve ulcer healing.

Screening for renovascular hypertension in a population with relatively low prevalence.

OBJECTIVE: To evaluate the accuracy and cost-efficacy of the diagnostic procedure and treatment for renovascular hypertension. SETTING AND PATIENTS: A total of 519 patients referred to the university clinic for hypertension were screened for renovascular hypertension with 405 captopril challenge tests (CCT) and 450 captopril renographies (CRG). INTERVENTIONS: Abdominal angiography was performed on 84 patients for positive screening. Fifteen patients underwent angiography for a sole suspicious clinical presentation. The angiography revealed 17 renal artery stenoses and five occlusions in 20 patients. Fifteen technically successful angioplasties and three nephrectomies were performed. RESULTS: In the patients who underwent angiography, CCT had a specificity of 39% and a sensitivity of 67% for renovascular hypertension. CRG had a sensitivity of 100% and a specificity of 68%. In the whole study population, the estimated specificity of CCT was 88% and that of CRG 95%. Invasive treatment reduced systolic/diastolic blood pressure from 157/99 to 140/87 mmHg and the number of antihypertensive drugs used from 2.6 to 1.4 in 16 patients (mean age 49 years). Angiotensin converting enzyme (ACE) inhibition was effective in four elderly patients. Cost-efficacy analysis Screening with CRG and invasive treatment cost US$15400 per successful invasive treatment Equally effective pharmacological treatment would have cost US$10400. Limiting the screening with CRG to the 173 patients with no obvious renal parenchymal disease and with hypertension at a younger age (< or =30 years) or unresponsive to two antihypertensive drugs (diastolic blood pressure > 90 mmHg) would have yielded a prevalence of 12% and missed only one elderly patient who responded to ACE inhibition. The limited screening, along with invasive treatment, would have cost US$7300 per patient CONCLUSIONS: CRG is superior to CCT for screening of renovascular hypertension. Screening with CRG is cost-effective when limited to patients with no obvious renal parenchymal disease and with hypertension that does not respond to two antihypertensive drugs or is detected in patients no older than 30 years.

Survival of a microvascular muscle flap despite the late occlusion of the inflow artery in a neuroischaemic diabetic foot.

A microsurgical free rectus abdominis flap was connected to a popliteodistal vascular reconstruction because of a limb-threatening ischaemic ulcer in an 84 year old diabetic patient. After six months the inflow vessel occluded, but the flap stayed viable, apparently receiving its nutrition through newly developed collaterals.

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.

Prognosis of patients over 75 years of age with a ruptured abdominal aortic aneurysm.

Forty-seven patients (34 males and 13 females) over 75 years of age (mean: 79.7 +/- 3.8 SD) suffering from a ruptured abdominal aortic aneurysm were operated on between 1977 and 1986. In 16 patients (34%), the aneurysm had been diagnosed previously. Seventeen patients (36%) had a delay of 6 hours or more in the beginning of the treatment and 26 (55%) were in shock preoperatively. The mean diameter of the aneurysms was 8.9 +/- 2.6 cm (SD) and the mean operative bleeding was 8.5 +/- 7.8 (SD) liters. The mean operating time was 220 +/- 96 (SD) minutes. The 1-month mortality was 60% (28 patients) and 63% (12 patients) of survivors had postoperative complications, mostly pneumonia. The 5-year survival rate was 26%. In the analysis of risk factors associated with death, preoperative shock, old age, and a previously diagnosed but untreated abdominal aortic aneurysm were associated with a significantly worse prognosis.

Lower limb haemodynamics during antihypertensive treatment with metoprolol and propranolol.

In order to evaluate the role of beta 1-selective beta-adrenoceptor blockade on lower limb haemodynamics, blood pressure, leg blood flow and vascular resistance were measured at rest and during reactive hyperaemia in 34 hypertensive patients. The study was performed as a randomized double-blind cross over trial involving four weeks' treatment with the beta 1-selective metoprolol 100 mg b.i.d., the non-selective propranolol 80 mg b.i.d., and placebo b.i.d. Blood pressure was equally reduced by both beta-adrenoceptor blocking drugs. Reactive hyperaemic blood flow decreased by 19% (p less than 0.01) during propranolol and by 14% (p less than 0.01) during metoprolol treatment, when compared to placebo. Vascular resistance, however, was unaltered by these drugs. There were no significant differences between beta 1-selective and non-selective beta-blockade on lower limb haemodynamics in hypertensive patients. As the reason for diminished reactive hyperaemic blood flow we suggest a beta-blocking effect on the heart rather than a peripheral mechanism.

Predictive value of preoperative segmental blood pressure measurements in below-knee amputations.

Segmental blood pressure criteria for below-knee amputations were assessed retrospectively. 40 patients underwent 44 below-knee amputations for advanced lower limb ischaemia. Preoperative systolic blood pressure measurements using a Doppler device as a distal sensor were performed on 31 limbs to be amputated. Healing occurred in all limbs with calf systolic pressures of 68 mmHg or more and distal thigh systolic pressures of 100 mmHg or more. With calf pressures below 35 mmHg and distal thigh pressures of 60 mmHg or less, all amputations failed. Diabetes did not affect the pressure criteria except for one obvious case with mediasclerosis. It appeared that pressure data could be used to improve the preoperative assessment of the amputation level.