In situ bypass to the dorsalis pedis and tibial arteries at the ankle.

Over a three-year period (1984-1987), we performed 98 in situ saphenous vein bypasses to the tibial arteries in 89 patients. In 68 of these grafts, the distal anastomoses were above ankle level. All but one of these grafts were performed for limb salvage indications. Seven (10%) of these grafts were done in patients on chronic renal dialysis. In 30 grafts, the distal anastomoses were to the ankle level. Indications for surgery were risk of limb loss in all these patients, with tissue loss in 29 (97%). Six (20%) were done in patients on chronic renal dialysis. Operative mortality was 3% in both groups. Late mortality was 13% in the above-ankle group, and 27% in the ankle level group. Secondary patency for the above-ankle group was 97%, 85%, 81%, and 81% at 30 days, one year, two years, and three years. Primary patency was 91%, 67%, and 58% at 30 days, one year, and two years, after which the standard error is greater than 10%. Secondary patency for the grafts at the ankle level was 100% and 82% at 30 days and one and one-half years. Primary patency rates were 93% and 68% at 30 days and one year. In situ bypass grafts at the ankle level had patency rates equivalent to grafts with distal anastomoses above the ankle. Patients with distal bypasses usually presented with tissue loss and had a higher late mortality rate. Careful follow-up and operative intervention when changes in graft velocities or indices are recognized, markedly improves the durability of the in situ saphenous vein bypass.

Classification of carotid bifurcation disease using quantitative Doppler spectrum analysis.

Spectrum analysis of continuous-wave Doppler recordings from the region of the carotid bifurcation was used to classify the degree of stenosis in the internal (ICA) and external (ECA) carotid arteries. Measurements of systolic peak frequency, end-diastolic frequency, and the degree of spectral broadening were used to define five ICA disease categories: 0% to 15% diameter reduction (DR), 16% to 49% DR, 50% to 80% DR, greater than 80% DR, and occlusion. The results were compared to contrast arteriography in 122 patients (243 arteries). The agreement with angiography in classifying ICA stenosis was 82%. Doppler spectrum analysis identified 96% of hemodynamically significant disease (greater than 50% DR) in the ICA and ECA and 97% of ICA occlusions. Attention to the common carotid artery waveform and the ICA diastolic frequency improved the accuracy of predicting greater than 80% DR and occlusion of the ICA. Noninvasive classification of carotid bifurcation disease is useful in clinical decision making to select the angiographic technique most likely to accurately define disease morphology and to follow up patients for disease progression.

Lessons learned in adopting the in situ saphenous vein bypass.

A 3-year experience with in situ saphenous vein bypasses was analyzed to evaluate the suitability of the conduit, the effect on vein utilization rate, the ease of valve ablation, the incidence of persistent arteriovenous (AV) fistula, the duration of the operation, and the nature of the learning curve to become adept at this technique. From 1981 through 1983, 74 patients underwent 55 femoral-tibial and 23 femoral-popliteal in situ saphenous vein bypasses. The operative indications were threatened limb loss in 76 (97%) and disabling claudication in 2 (3%); 35 of 74 patients (48%) were diabetic. In the last year pulsed Doppler spectrum analysis was added to arteriography for intraoperative graft assessment. For 55 femoral-tibial grafts measured by life-table patency rates at 30 days, only one femoral-popliteal graft failed (1 1/2 years). Complete vein utilization was accomplished in 91% of the bypasses attempted. In 41 of the 78 (51%) grafts, vein diameter was 3.5 mm or less. Operative time decreased with experience. Pulsed Doppler spectral analysis has proved useful for intraoperative graft evaluation. The in situ saphenous vein has become the conduit of choice for infrageniculate bypass.

Management of injury to the spleen in adults. Results of early operation and observation.

Seventy-seven adults with splenic trauma were treated at a Level I Trauma Center during a 4-year period. Sixty-seven patients had early operation (55 splenectomy, nine splenorrhaphy, three partial splenectomy). Ten adults with stable vital signs were initially managed by observation without operation. Patients who had other intra-abdominal injuries were more likely to have an early operation and splenectomy. Patients who had a lesser transfusion requirement were more likely to have initial nonoperative management. Only three of the 10 patients who were managed initially by observation avoided eventual operation. Six of the seven patients who failed observation management required splenectomy. Patients with isolated splenic injuries had a significantly shorter hospital stay after an early operation than after observation without operation (p less than 0.05). We recommend early operation for the management of splenic injury in adults. Observation of isolated splenic injuries frequently is unsuccessful in adults and unnecessarily prolongs hospital stay.

Complications of diverticular disease: a review of the barium enema findings.

Complications of diverticular disease are among the most common causes of all acute hospital admissions. The barium enema is the most important investigation in these patients, both for establishing the diagnosis and planning their management. However, few comprehensive reviews have described the radiological appearances of the complications of diverticular disease. We describe the radiological features and emphasize the diagnostic difficulties that may occur.