Decreased nitric oxide production following extremity ischemia and reperfusion.

BACKGROUND: Nitric oxide (NO), the endogenous vasodilator, is an important regulator of vascular tone. We investigated NO production following lower extremity ischemia. METHODS: Rabbits underwent 6 hours of bilateral leg ischemia followed by unrestricted reperfusion. Physiologic parameters were continuously measured and blood was assayed for NO2 and NO3. RESULTS: Acute ischemia of the lower extremities produced an immediate increase in mean arterial blood pressure while later reperfusion induced a significant decrease (P < 0.0005). There was a fall in femoral blood flow during reperfusion. NO2/ NO3 concentrations decreased significantly to 89% of baseline values after ischemia and 77% after 1 hour of reperfusion (P < 0.005). A significantly higher mortality was found in association with decreased NO2/NO3 concentrations. CONCLUSIONS: Nitric oxide appears to be a regulator of regional blood flow during reperfusion following extremity ischemia. Decreased NO production may contribute to impaired regional blood flow and mortality.

Inappropriate use of venous duplex scans: an analysis of indications and results.

PURPOSE: The increasing demand for venous duplex scans despite the relative rarity of detecting acute deep venous thrombosis (DVT) prompted us to review our experience with this diagnostic method. METHODS: We retrospectively analyzed the results and indications of 2993 lower extremity venous duplex scans performed between July 1, 1992, and June 30, 1994, at our institution. The indication for the study and the results were prospectively recorded in a computerized data bank. The indications for these studies were leg pain (34%), leg swelling (24%), surveillance for DVT in a patient at high risk (23%), searching for a source of pulmonary embolism (14%), follow-up of previously diagnosed DVT (3%), and other indications (i.e., varicose veins, venous ulcer, 2%). RESULTS: Overall, 74.1% of all scans were completely normal, and only 13.1% detected acute proximal (popliteal vein or higher) DVT. Scans performed for surveillance (87.3% normal) or source of pulmonary embolism (79.6% normal) were significantly more likely to be normal than when performed for any other indication (p < 0.01). When leg edema or calf tenderness was present, the incidence of acute DVT was significantly greater for all indications (p < 0.0001). CONCLUSIONS: The high percentage of normal venous scans implies that this diagnostic method is being inappropriately used. In the current climate of cost containment our data suggest that indications for venous duplex scans must be better defined and that improved education for referring physicians is needed.

Contralateral duplex scanning for deep venous thrombosis is unnecessary in patients with symptoms.

PURPOSE: Bilateral lower extremity venous duplex scanning for acute deep venous thrombosis (DVT) has been advocated because of the high incidence of occult contralateral leg involvement. We investigated the clinical necessity of such a policy. METHODS: The results from 2996 venous duplex studies performed during the past 2 years were retrospectively reviewed. A total of 1694 of these scans were performed on patients with symptoms, of whom 248 (15%) were found to have an acute DVT. Symptoms were limited to one side in 198 patients, whereas bilateral complaints were noted in 50 patients. RESULTS: Among the patients with symptoms of acute DVT, 72 (29%) had bilateral involvement. Bilaterality was more likely in patients with bilateral symptoms than in those with only unilateral symptoms (56% vs 22%; p < 0.005). Of the patients with unilateral symptoms and bilateral DVT, all of them had either acute (80%) or acute and chronic (20%) thrombosis in the symptomatic leg. The contralateral asymptomatic limb had fewer acute and more chronic DVT (41% and 55%, respectively). No patient from the entire group admitted with symptoms had an acute DVT in the asymptomatic limb without a concomitant acute DVT in the symptomatic leg. Unilateral scanning would decrease the examination time by 21% and potentially increase total reimbursement for symptomatic venous scans by 9% compared with routine bilateral duplex scanning. CONCLUSIONS: Although bilateral involvement is frequent in patients with symptoms of acute DVT, treatment in these patients is not altered by this finding. We conclude that contralateral venous scanning in patients with unilateral symptoms is not clinically indicated and that unilateral scanning would result in improved cost-efficiency for vascular laboratories.