Peripheral arterial emboli and factors in their recurrence rate.

One hundred six patients who underwent a total of 141 operations, on 156 limbs for peripheral arterial emboli from 1964 to 1979 were studied. The average age of the patients was 68.5 years. The source of the emboli in 76.4% of the patients was arteriosclerotic heart disease and atrial fibrillation. The presenting clinical symptoms and signs were the most accurate determinate of limb salvage. Our overall limb salvage was 86.5% and in the survivor population 93.9%. The overall hospital mortality was 21.7%. There were much higher morbidity and mortality rates associated with each subsequent embolic event. Particular attention was paid to factors related to recurrent emboli. The use of antigoagulants in the post embolectomy period does not have a statistically significant effect of preventing recurrent emboli.

Long-term results of operative therapy for aortoiliac disease.

Over a period of 11 1/2 years, 140 patients were operated on for aortoiliac disease; 81 had coexisting superficial femoral artery occlusions (combined segment disease). Patients with combined segment disease were older, had twice the incidence of diabetes, and significantly more rest pain and gangrene on presentation. Aortic bifurcation grafts were placed in 114 patients. Relief of rest pain and threatened gangrene was uniformly good. However, relief of claudication was significantly poorer in patients with combined segment disease. There were 11 "late" thrombotic graft occlusions. Six grafts with distal anastamoses to the external iliacs failed because of limb outflow problems, while five grafts to the common femoral position exhibited more diffuse problems. Late graft failures were due to progression of disease and not problems intrinsic to the grafts. Cumulative patency rates were 98.0% at one year and 94.6% at three years.

Dacron grafting from the aorta to the distal profunda femoria arteries via the obturator foramina.

We discuss the possibility of the use of the obturator foramina as routes and the distal profunda femoris arteries as sites for anastomosis in the presence of infected grafts in the groins as a successful solution to an otherwise tragic complication of arterial grafting.

Combined aortoiliac and femoropopliteal occlusive disease.

In a series of 140 patients operated upon for aortoiliac occlusive disease over 11 1/2 years, 81 had concomitant occlusion of the superficial femoral artery. These 81 patients with combined segment disease were studied with particular emphasis on the relief of presenting symptoms by an aortic bypass procedure alone. Fifty-three patients underwent only aortic bypass and could be fully evaluated postoperatively. Ninety-six per cent presenting with rest pain or ischemic changes obtained complete relief of these sympotms. All 53 patients presented with claudication, and 88.7 per cent either had complete relief or improved to the point that no further theapy was needed. The results of this study confirm the efficacy of restoration of proximal flow to the profunda femoris arteries as the primary therapeutic goal in patients with combined segment disease.

Intravascular coagulation in surgical procedures on the abdominal aorta.

A prospective study was performed on 32 consecutive patients undergoing elective operations on the abdominal aorta. Dacron prosthetic grafts were used to replace resected abdominal aortic aneurysms or to bypass aorta-iliac occlusive disease. Complete coagulation studies were performed preoperatively, immediately postoperatively and 24 hours postoperatively. Twenty to 30 per cent of the patients had significant postoperative alterations in prothrombin time, partial thromboplastin time and platelet count. Fibrin monomer, fibrin split products and plasminogen were abnormal in 40 to 80 per cent of the patients postoperatively. Results of preoperative studies showed no significant abnormalities. One of the 32 patients had mild clinical evidence of disseminated intravascular coagulation postoperatively, which was treated with 5 units of heparin per kilogram per hour. Results of the study indicate that aortic grafting procedures frequently produce intravascular coagulation, either local or disseminated. In most patients, this is offset by activation of the fibrinolytic system. However, clinically significant sequelae may result, requiring prompt recognition and treatment.

Disseminated intravascular coagulation as a complication of abdominal aortic aneurysm repair.

A retrospective review was done of all patients undergoing surgical repair of abdominal aortic aneurysm (AAA) on whom coagulation studies were obtained. Those patients with laboratory documented disseminated intravascular coagulation (DIC) were selected and their clinical records reviewed. This included 7 patients studied in the periods 1964-1965 and January 1971-July 1973. Of these 7 cases, 4 occurred in patients undergoing emergency operation for ruptured aneurysm and 3 were in elective cases. All 7 patients exhibited clinical evidence of abnormal bleeding, while 6 of the 7 progressed rapidly to renal shutdown. The seventh patient recovered spontaneously. Of the 6 patients with full blown clinical and laboratory evidence of DIC, 2 recovered. Both cases received heparin therapy and multiple hemodialyses. A third patient was started on heparin but died at 36 hours in heart failure. All 3 patients receiving heparin showed clinical cessation of abnormal bleeding and disappearance of soluble fibrin monomer complexes within 24 hours of starting therapy. The study suggests a higher incidence of DIC than has previously been appreciated in both the emergency and elective repair of AAA. The prompt recognition and treatment of this complication may reverse the abnormal intravascular clotting, minimize its more serious results and avoid futile and dangerous operative intervention.