The surgical history of the amputated limb according to the indication for revascularization: diabetic foot, acute ischaemia, aneurysmal disease, chronic arterial occlusive disease.

BACKGROUND: To investigate whether the indication for the first revascularization (diabetic foot, acute ischaemia, aneurysmal disease, chronic occlusive disease) determines the surgical history and survival time in amputated limbs. METHODS: The surgical history of lower extremities amputated between 2002 and 2009 was reviewed for the number of (endo)vascular procedures, minor amputations, wound debridements, complications requiring surgery (acute ischaemia, bleeding, graft infection) and limb survival time (LST). RESULTS: 100 limbs were included in the study. The four groups underwent a similar number of surgical procedures (mean 4.1). Diabetic foot limbs had fewer revascularizations (mean 1.3, p = 0.003) and complications (mean 0.1, p = 0.005), but more minor amputations and wound debridements (mean 1.3, p = 0.002), in a significantly shorter LST (mean 555 days, p = 0.003). Acute ischaemic limbs showed the shortest LST (mean 179 days, p = 0.003) and significantly more complications (mean 0.8, p = 0.005). Limbs initially treated for aneurysmal disease or chronic occlusive disease had the highest number of revascularizations (mean resp. 2.7 and 2.6) and the longest LST (mean resp. 1669 and 1459 days, p = 0.001). Limbs with advanced chronic occlusive disease (rest pain or gangrene) presented with fewer revascularisations (mean resp. 2.5 and 1.8, p = 0.01) and a shorter LST (mean resp. 1284 and 794 days, p = 0.004) compared to claudicants. CONCLUSIONS: Our study suggests that the surgical history and limb survival in amputated limbs is disease and stage specific, and determined by the indication of the first revascularisation.

Gender differences in cardiovascular risk factors in a carotid endarterectomy population.

AIM: Present knowledge about the epidemiology and the distribution of the cardiovascular risk factors of carotid artery atherosclerosis is limited. The aim of the study was to detect possible gender differences in cardiovascular risk factors in carotid endarterectomy patients. METHODS: Between 1998 and 2003 the cardiovascular risk factors of 804 consecutive isolated carotid endarterectomies were prospectively recorded. The data of 567 men and 237 women were compared and subgroup analysis of young and old male and female subjects was performed. RESULTS: The number of cardiovascular risk factors per patient is higher in men, hypertension is more predominant in women, tobacco use is twice as often present in men. The most frequent risk factors are, in men, tobacco use and hypertension, and, in women, hypertension and hyperlipidemia. The most frequent combination in the male group is tobacco/hypertension/hyperlipidemia and in the female group hypertension/hyperlipidemia. The gender differences were more striking in patients younger than 75 years, after this age the number of cardiovascular risk factor per patient declined in both sexes, the number of smokers decreased but remains higher in men, diabetes is more frequent in women and hypertension and hyperlipidemia become the important risk factors in men as well in women. CONCLUSIONS: There are gender differences in the distribution and in the combinations of cardiovascular risk factors in our selected patients. These findings suggest that screening for carotid artery atherosclerosis should particularly be aimed at people with the combinations of risk factors described above.

A key to understanding postoperative lymphoedema: a study on the evolution and consistency of oedema of the arm using ultrasound imaging.

Post-mastectomy oedema is a very serious complication that, in the course of time, will transform into fibrotic tissue. The aim of our study is to evaluate when and in which layer liquid oedema transforms into fibrotic tissue. To do so, ultrasonographic images were taken of 22 patients and 9 control women at the shoulder and 10 cm proximal and distal from the olecranon, with the images then being scanned and imported into a computer program to determine echogenicity of the dermis, subcutis, subcutis on dermal side and subcutis on fascial side. Statistical analyses were performed by means of the Wilcoxon test and a Student's t-test. No significant differences (P< or =0.05) were found for the different parameters in the control group. In the experimental group: significant differences in perimeter, skinfold, thickness of dermis and subcutis were found. Although not significant, subcutaneous tissue was more echogenic on the oedematous side, with significant hyperechogenicity at the fascial subcutaneous layer. This indicates that fibrotic tissue develops distally in the forearm.

Spontaneous dissection of the abdominal aorta.

Spontaneous abdominal aortic dissection is a rare entity, often with a clinically unspecific presentation. The cause of the dissection is unclear. Angiography used to be the definitive diagnostic study, but today a correct diagnosis can be achieved with CT scanning and magnetic resonance angiography. The optimal form of management for the individual patient is not clearly established. Chronic dissections may best be managed conservatively, with close follow-up achieved with CT scanning and magnetic resonance. Acute and complicated dissections should be treated surgically with aortic and aortic branch replacement if it can be offered with low morbidity and mortality. In selected cases, resection of the ischemic organs may represent an alternative.

Desmin (a low molecular weight dermatan sulphate) versus heparin in the treatment of patients with deep venous thrombosis.

OBJECTIVE: There is theoretical and experimental evidence which indicates that Desmin, a low molecular weight dermatan sulphate, could be an attractive alternative to heparin in the treatment of deep venous thrombosis (DVT). The present study compares both compounds in patients with established DVT. METHODS: Seventeen consecutive patients admitted with DVT were included in a randomised open study comparing continuous intravenous administration of Desmin and continuous intravenous administration of heparin. Clinical, laboratory and imaging parameters were used to assess the efficacy and safety of both treatments. RESULTS: The results of the coagulation tests confirmed the published data on the antithrombotic profile of Desmin. A trend towards better biochemical tolerance was observed with Desmin. Repeated echo duplex examinations of the deep venous system could not document further thrombus extension in any patient. Pre- and post-treatment phlebographic Marder scores showed a non-significant trend towards superior efficacy of Desmin. Overall, the results regarding efficacy and safety were not significantly different in the two groups. CONCLUSION: Desmin can be safely studied as an alternative to conventional anticoagulation in the treatment of DVT.

Intra-arterial thrombolysis followed by elective surgery for thrombo-embolic popliteal aneurysms.

Two patients with acute limb-threatening lower extremity ischaemia as a result of a thrombosed and embolizing popliteal artery aneurysm are described. Both patients were successfully treated with intra-arterial thrombolysis and subsequent elective vascular reconstruction. Thrombolysis might be an effective method to identify the underlying cause of limb ischaemia and to recanalize the run-off vessels leading to better bypass patency rates. However, this management is only indicated in selected cases of acute limb ischaemia without motor or sensory deficit.

Screening for concomitant diseases in peripheral vascular patients. Results of a systematic approach.

BACKGROUND: Patients considered for arterial surgery, have been shown to have a high incidence of coexistent cardiac, vascular and other diseases, affecting operative risk and survival. We developed a systematic workup strategy for detecting these coexistent diseases in our vascular surgical patients, mainly based on non-invasive diagnostic techniques. METHODS: We evaluated 200 consecutive patients, admitted to the department of vascular surgery in an academic teaching hospital, in order to establish the total incidence of relevant concomitant disorders, the extent to which this screening yielded previously unknown diagnostic information, and the impact on short-term (one year) survival. RESULTS: Coronary artery disease was present in 46% of the patients; 22% had active ischaemia, newly diagnosed in 5.5%. Impaired cardiac function was found in 37%: severely impaired in 12%, newly diagnosed in 27%. Carotid artery disease was present in 32%: critical stenoses were found in 9%; new diagnoses in 29.9%. Aortic aneurysms were present in 7%, newly diagnosed in 5%. Severe renal artery stenosis was present in 5%, newly diagnosed in 3.5%. Sixteen % of the patients had chronic obstructive pulmonary disease, newly diagnosed in 3.5%, and 4.5% had unexpected disorders, which were all new diagnoses. Overall, new diagnoses were reached in 64.5% of the population, affecting therapeutic strategy immediately in 21% of the patients. The presence of coronary artery disease and of cardiac failure were clearly related to one year survival. CONCLUSIONS: We conclude that a systematic screening strategy, mainly based on noninvasive techniques, can detect the presence of concomitant diseases in the vascular surgical patient. Most important seem the newly diagnosed diseases altering surgical management in one out of every five patients; they also have important implications for patient prognosis.

Laser Doppler flux characteristics at the skin of the dorsum of the foot in young and in elderly healthy human subjects.

In aged human subjects the cutaneous circulation has shown reduced vasoreactive capacity when stimulated by heat or ischemia, and autonomic dysfunction developing in the elderly was suggested. Should this autonomic dysfunction affect the arteriolar vasomotional activity, it might be demonstrated by laser Doppler fluxmetry (LDF) at rest. LDF flow motion characteristics at the dorsal foot skin were investigated under resting conditions in two subject groups differing in age. The younger group (n = 27, aged 25-29 years) showed a resting flux of 3.0 +/- 1.0 Arbitrary Units (AU) and a flux amplitude of 0.34 +/- 0.13 AU. In the elderly group (n = 22, aged 60-92 years) both these values were significantly (P < 0.05) lower (2.4 +/- 0.5 and 0.18 +/- 0.05 AU, respectively). The flux frequency, on the contrary, was similar in both age groups: 4.9 cycles min-1. We conclude that the mean resting flux and the mean flow motion amplitude under resting conditions at the skin of the dorsum of the foot are significantly reduced in an old-age group. The latter finding might be an aging phenomenon affecting the microvascular tone and reactivity, and might be one of the elements responsible for the attenuated cutaneous vasoreactivity described in elderly humans in response to heat and ischemic stress.

Preoperative cardiac management of patients undergoing non cardiac surgery.

The estimation of an individual patient's "resistance" to major surgery has become an complex matter. Clinical parameters allow risk stratification in a large number of patients who are about to undergo noncardiac surgery. Low risk patients can be "cleared" for surgery. Moderate risk patients should undergo further testing. Exercise testing and pharmacological stress testing with myocardial perfusion imaging can refine risk estimation in these patients. This risk stratification is well backed by scientific data, although most of it is derived from studies in the same very high risk population, i.e. patients scheduled for vascular surgery. Less hard evidence exists when it comes to the management of the high-risk patient. Coronary bypass surgery should probably be reserved for those in whom additional indications for this procedure exist. The perioperative use of beta-blockers can possibly reduce operative risk. Data on perioperative monitoring and anesthetic technique are not yet convincing. The relative merits of various perioperative management strategies will remain uncertain until randomised trials are performed to evaluate the alternatives systematically.

Laser Doppler resting fluxes, flux motion frequencies and amplitudes at the skin of the dorsum of the foot in healthy young humans.

The complex microvascular geometry and the spatially heterogeneous perfusion of the skin seem to limit the application of Laser Doppler flowmetry (LDF) in resting conditions because of the large spatial variations that these microvascular measurements can show in even very adjacent areas of the dermal mantle. In this study cutaneous LDF was carried out at three spatially different areas of the dorsum of the foot in 22 young (mean age 25.5 years) and healthy human subjects: microvascular resting flux, flux frequency and flux amplitude as well as the distal tissue perfusion pressure as a macrovascular parameter and the skin temperature were measured. Intraindividually marked variations of the microvascular variables often existed between the three areas, but the variability was significantly different (p < 0.001): the resting flux yielded a variation coefficient (VC) of 36.2%, the amplitude of flux waves a VC of 20.2%, while the frequency of flux waves was a very precise individual parameter (VC 7.4%). Interindividually the variation of all three flux parameters was still significantly greater than intraindividually, but the mean value of all the subjects was the same in all three areas: mean resting flux was resp. 2.32, 2.23 and 2.44 arbitrary units (AU); mean frequency of flux waves 5.15, 4.96 and 4.90 cycles min-1; mean amplitude of flux waves 0.34, 0.36 and 0.36 AU. At last, no correlation existed between any of the microvascular flux variables on the one hand and the distal tissue perfusion pressure and skin temperature on the other hand.(ABSTRACT TRUNCATED AT 250 WORDS)

Transbrachial approach for aortic and selective supraaortic vessel catheterization using a safe and easy technique to reform the Simmons II catheter tip.

A total of 286 patients (158 outpatients) were examined by intra-arterial DSA in the evaluation of cerebrovascular disease using a transbrachial approach. In all cases a 5F introducer sheath, a 5F pigtail catheter for aortic arch injection and a 5F Simmons II catheter for selective catheterization were used. Excellent demonstration of aortic arch and supraaortic arteries (including intracranial circulation) was obtained (92.2-100%). The complication rate was favorable, with only one major complication (thrombosis of an axillary artery). The use of an introducer sheath minimizes local complications and vessel wall damage during catheter exchange. Aortic arch injection must always be performed prior to selective catheterization. The results of selective catheterization prove the suitability of the Simmons II catheter, whose typical shape was easily and safely obtained using the configuration of the pigtail catheter and a 180 cm long guide wire for catheter exchange. Using the technique as described, the transbrachial approach is a safe and easy way for optimal vascular evaluation in cerebrovascular disease, especially useful in outpatients.

Muscular fibrosis due to chronic intramuscular administration of narcotic analgesics.

Chronic intramuscular injections, particularly of narcotic analgesics, are an uncommon cause of myopathy. We report two patients with pentazocine- and meperidine-related myopathy. Narcotic-induced muscular fibrosis and contractures must be considered in patients with a pattern of muscle involvement that does not conform to any recognized myopathy, but allows for self-administration of injections. Trauma due to needle puncture, repetitive infections and a local myotoxic effect of the drugs probably contribute to these lesions.

Echocardiography and magnetic resonance imaging in cardiac amyloidosis.

Cardiac amyloidosis is an uncommon cause of heart failure. Based on an observation of immunocytic cardiac amyloidosis with a fatal course, the diagnostic modalities are reviewed with special emphasis on echocardiographic findings. The possible role of magnetic resonance imaging is discussed.

Hematuria as presenting sign in Wissler-Fanconi syndrome.

We describe a case of persistent microscopic hematuria as initial finding in incomplete Still's disease or Wissler-Fanconi syndrome. Renal biopsy findings were compatible with intravascular coagulation. Wissler-Fanconi syndrome and the associated renal abnormalities are briefly reviewed.

Group B streptococcal endocarditis mimicking mitral valve myxoma.

A patient with group B streptococcal endocarditis and large vegetations resembling mitral valve myxoma is described. Group B streptococcal endocarditis and the differential diagnosis of vegetations and cardiac tumors are briefly reviewed.