[Primary results of vascular surgery in lower limbs threatened with amputation].
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Biomedical subjects
J H Eickhoff
Publications and source records attributed to J H Eickhoff.
Pre-operative exercise testing in patients suspected of arteriosclerotic heart disease: methods, risks and reproducibility.
In order to estimate the value of haemodynamic parameters in assessing impaired left ventricular function the reproducibility of haemodynamic measurements were investigated at rest and during supine exercise on a bicycle ergometer in fifty-one patients suspected of arteriosclerotic heart disease by means of a Swan-Ganz pulmonary artery thermodilution catheter and a radial artery catheter. Furthermore the minimal significant (P less than 0.05) change from rest to exercise was determined. In conclusion we found that haemodynamic measurements during exercise testing estimate left ventricular function in a safe and reproducible manner. A rise in pulmonary capillary wedge pressure (PCWP) of only 0.9 kPa during exercise was significant, whereas changes in stroke volume index (SVI) were considered significant only when exceeding 9 ml/m2.
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Revascularisation of the lower limb.
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The effect of single dose ergotamine tartrate on peripheral arteries in migraine patients: methodological aspects and time effect curve.
Ergotamine tartrate (0.5 mg/70 kg) was given intravenously to 17 migraine patients. Arm, finger, ankle and big toe systolic blood pressures were measured with strain gauge technique for up to 4 hours and again after 22 hours. Systolic arm blood pressure increased transiently (duration less than 3 hours). Peripheral systolic blood pressures decreased in all patients (for toes a few to 55 mmHg) and at 22 hours well sustained decreases were still found. Further 10 migraine patients received 2-4 mg ergotamine tartrate as suppositories and peripheral systolic blood pressures were measured for 3 days. A decrease in peripheral systolic blood pressure was found after 24 hours but had disappeared after 48 hours. Contrary to common belief the present study investigating the effect of ergotamine directly on arteries has shown a long duration of its vasoconstrictory effect. Thus the effect of a single dose of ergotamine on the arteries should be followed for days.
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Diagnostic correctness of distal blood pressure measurements in patients with arterial insufficiency.
The value of distal blood pressure measurement by strain gauge technique in arterial insufficiency was analysed by means of the so-called direct method for evaluation of diagnostic tests, and by the calculation of the diagnostic specificity (predictive value of a positive test), the diagnostic sensitivity (predictive value of a negative test), and the diagnostic correctness (the proportion of patients correctly classified by the test). A blood pressure gradient greater than or equal to 20 mmHg from arm to ankle had a high diagnostic correctness as a screening procedure for arterial insufficiency among forty out-patients. Likewise, in sixty-seven patients admitted for arterial reconstruction a toe blood pressure < 30 mmHg had a high diagnostic correctness in deciding whether constant pain was in fact ischaemic rest pain. In contrast, distal blood pressure measurement was of no value as an indicator of the walking distance of claudicants or in locating the arterial obliterations. It is proposed, that similar evaluations are performed on other tests for arterial insufficiency.
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Effect of arterial and venous pressures on transcutaneous oxygen tension.
The effect of changes in arterial and venous pressures on transcutaneous oxygen tension (tcPO2) were studied in ten young subjects. The tcPo2 electrode was mounted on the foot, and changes in blood pressures were induced by elevating and lowering the foot and by inflating a cuff around the thigh. tcPo2 decreased gradually during elevation at a rate of 1% per mmHg reduction in arterial pressure. tcPo2 increased during dependency and venous stasis, at a rate of 0.5% per mmHg increase in venous pressure. We propose that tcPo2 is a function of the blood flow under the electrode, and that normal blood flow regulation is abolished in the heated tissue under the electrode.
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Correlation of transcutaneous oxygen tension to blood flow in heated skin.
Blood flow regulation in the foot under a heated (43 degrees C) transcutaneous oxygen tension (tcPo2) electrode was studied in six young subjects. Blood flow under the electrode was estimated from the electrical power consumption of the thermostatistically-controlled heating element in the electrode. Changes in arterial and venous pressures, and thereby in perfusion and transmural pressure and blood flow were induced by elevation and lowering of the foot and by venous stasis. tcPo2 was significantly and positively correlated to the blood flow under the electrode, and blood flow neither showed autoregulation nor vasoconstrictor response as judged from the power consumption. In contrast the blood flow in normal unheated skin measured simultaneously by the 133-Xenon technique showed autoregulation as well as vasoconstrictor response. It is concluded that tcPo2 is a parameter determined by many variables, of which the arterial blood pressure is of particular clinical importance.
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The iliac vein compression syndrome. A case report with a review of the literature.
The iliac compression syndrome results from reduced venous return from the left leg due to pressure from the right common iliac artery on the underlying left common iliac vein where it enters the inferior vena cava. The pressure results in intravenous band and adhesion formation which can lead to iliofemoral thrombosis with insufficient recanalization. We present such a case in a young man who had swelling, venous claudication, siderosclerosis, and skin ulcers. The syndrome was diagnosed by pelvic phlebography, arteriography, venous emptying time, and venous pressure measurement. Palma's crossover operation was performed, in which the contralateral great saphenous vein was transposed subcutaneously to the ipsilateral common femoral vein peripheral to the obstruction. To avoid graft thrombosis, a temporary arterio-venous fistula was created. Follow-up six months after the operation showed the operative result to the satisfactory.
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A comparison of the strain-gauge and the Dohn air-filled plethysmographs for blood flow measurements in the human calf.
Blood flow measurements using either a strain gauge plethysmograph or the Dohn air-filled plethysmograph were compared by means of successive measurements in the calf in six normal subjects (12 extremities) and in five patients with arterial insufficiency (nine extremities). Flows were recorded during rest as well as after 5 minutes of ischemia. The strain-gauge plethysmograph tended to give lower values than the Dohn plethysmograph, although at higher flow rates the results were identical. It is concluded that, for most purposes, the Dohn plethysmograph can be replaced by the strain gauge plethysmograph, which is considerably simpler to use.
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The effect of arterial reconstruction on lower limb amputation rate. An epidemiological survey based on reports from Danish hospitals.
During the period 1 April-31 December 1976, the incidence rates of admission, of amputation and of arterial reconstruction for arteriosclerosis of the lower limbs were calculated from information in the Danish National Patient Register. Admissions increased with age (from 4.3 per 100,000 persons under 40 years of age per year to 1603 per 100.000 persons over 80 years per year). Similarly, lower limb amputations varied with age (from 0.3 to 226 per 100.000 persons per year). Arterial reconstructions, however, did not vary with age, but remained rather constant at about 50 per 100.000 persons per year, in persons over 50 years. The incidence rates of admissions, amputations and arterial reconstructions in men were 1.5 x the incidence rates in women. Both amputation and arterial reconstruction showed a significant regional variation from county to county. However, the rates were not correlated, and the expected amputation-preventing-effect of arterial reconstructions could not be demonstrated. The most probable cause for this was the inadequate capacity for vascular surgery in Denmark. An estimation shows that of the 1100 operated on for severe lower limb ischemia during the period studied, only 290 were offered arterial reconstruction.
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Evaluation of patients with only marginally abnormal arm-ankle blood pressure gradients suspected of arterial obliterative disease.
Two groups of patients with only marginally abnormal systolic blood pressure gradients from arm to ankle were studied. Group A consisted of 24 patients, who had arteriography performed for unilateral symptoms. In the non-symptomatic limbs a significant correlation was found between the severity of obliterations and the arm to ankle blood pressure gradients, which in all cases was less than 35 mmHg. In Group B consisting of 55 patients suspected of arterial obliterative disease the arm to ankle pressure gradient was measured at rest and after 2 min. of leg exercise. The diagnostic correctness of the two procedures were analysed by the direct method for evaluation of diagnostic tests using the clinical diagnosis as final diagnostic criterion. The maximal diagnostic correctness was 85 % for the gradient at rest using values between 20 and 25 mmHg as criterion for arterial obliterative disease. It equaled the maximal diagnostic correctness of 87 % of the gradient after exercise using values between 45 and 55 mmHg as criterion.
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Measurement of central hemodynamic parameters during preoperative exercise testing in patients suspected of arteriosclerotic heart disease. Value in predicting postoperative cardiac complications.
The object of this study was to investigate whether the history, general clinical examination, chest radiography, ECG, and preoperative exercise haemodynamics afforded a basis for pointing out individuals who were likely to develop postoperative cardiac complications. Particular emphasis was placed on whether haemodynamic testing yielded a major contribution to predicting such complications. 48 patients carried out preoperative exercise tests. The hemodynamic parameters were obtained by using a Swan-Ganz pulmonary artery thermodilution catheter. The clinical examinations, laboratory findings, and haemodynamic parameters were assessed by comparing the results with the outcome of the postoperative course. In assessing the results, the same diagnostic accuracy was found for the history (0.56-0.65), laboratory findings (0.50-0.65), and hemodynamic parameters (0.44-0.71). By combining the various parameters, however, it was possible to achieve a very high sensitivity (0.86) as regards the prediction of postoperative cardiac complications, but this was at the cost of many false positives and consequently a low accuracy (0.46). We conclude that haemodynamic exercise testing is not better than conventional means of prediction individual patient's postoperative cardiac complications.
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Forefoot vasoconstrictor response to increased venous pressure in normal subjects and in arteriosclerotic patients.
The local vasoconstrictor response to increased venous transmural pressure was studied in the forefoot in 18 normal subjects and in 43 patients with occlusive arterial disease of the lower limbs. Subcutaneous blood flow was measured by the local 133-Xenon wash-out technique. Blood flow measured 40 cm below heart level was compared to blood flow measured at heart level. In 18 normal limbs the vasoconstrictor response caused a decrease in blood flow to a median value of 73%, compared to a median value of 88% in 22 limbs with intermittent claudication without rest pain (p = 0.01). In limbs with ischemic symptoms at rest blood flow increased to a median value of 1.36, when the leg was lowered. Assuming that arterial and venous transmural pressures increase equally during lowering, corresponding to the hydrostatic pressure, keeping the perfusion pressure constant, then the changes in blood flow are due to changes in local peripheral resistance. The significantly smaller decrease in blood flow in claudicants is thus interpreted being due to a functional or structural adaptation of the arterioles to the chronic hypotension. The increase in blood flow during lowering in limbs with rest pain implies a diminished peripheral resistance caused by passive dilation of the arterioles by the increased transmural pressure.
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Müllerian duct cyst. Report of a case and review of the literature.
Stranguria in a 35-year-old man was caused by an orange-sized cyst of the Müllerian duct. The case is reported and the literature is reviewed. The most reliable diagnostic method is cystoscopic tubulation through the prostatic utricle. The simplest form of treatment is subsequent evacuation of the cyst through the tube. Alternatively, marsupialization of the posterior cyst wall at laparotomy is preferable to attempted extirpation, which is always difficult and usually gives rise to complications.
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Survival after arterial reconstruction in arteriosclerosis obliterans of the lower limbs. Follow-up after 10-20 years.
Cumulative survival rates were calculated for 144 patients subjected, 10-20 years previously, to vascular surgery for arteriosclerosis obliterans of the lower limbs. The five-, ten-, and fifteen-year survival rates were 71%, 49%, and 30% respectively, when calculated from the time of operation. The five-, ten-, fifteen, and twenty-year survival rates were 85%, 65%, 44%, and 23% respectively, when calculated from the onset of symptoms. This represents a considerable excess mortality, mainly among men, and mainly caused by arteriosclerotic diseases. However, the median survival time is 13 years from the onset of symptoms, and during this period it is of decisive importance, that patients with disabling symptoms get access to vascular surgical evaluation.
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Rehabilitation after arterial reconstruction of the lower limbs. A four to six years follow-up study.
The social fate of 105 patients was followed 4 to 6 years after arterial reconstruction of the arteries of the lower limbs. At the time of operation half of the patients had ischemic symptoms at rest. None died, and none were amputated as a result of the arterial reconstruction. In 84 per cent the operation aimed at restoring the working-capacity including the ability to do housework. In 11 per cent the aim was preservation of personal independence. Five per cent had non-disabling claudication. In 60 per cent the working-capacity was restored, and only 5 per cent were confined to nursing care. At the end of the follow-up period 74 per cent of the patients were alive, and of these 50 per cent had retained their working-capacity. Forty-five per cent were personal independent pensioners and 5 per cent were confined to nursing care. The majority of senescent patients, threatened by amputation of the lower limbs, will retain their personal independence after arterial reconstruction. The socioeconomic importance of this fact is stressed.
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Appendico-vesical fistula. A new case and a brief review of the literature.
A new case of appendico-vesical fistula is submitted. After a brief review of the literature, it is concluded that these fistulas usually manifest themselves clinically in recurrent urinary infections without gastro-intestinal symptoms. The best aids in the difficult diagnosis are cystography and cystoscopy. Treatment is by appendectomy and excision of the fistular opening.
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Ureteric necrosis after kidney transplantation.
Uretero-cystostomy was used as reconstructive procedure in 298 cadaver kidney transplantations. Necrosis of the graft ureter occured in 10 cases (3.4%). 2 of these graft ureters had malformations and 1 was denuded at donor nephrectomy. The occurrence of ureteral necrosis was not related to histocompatibility or number of rejection crises nor to the duration of the warm ischemia. A higher incidence of ureteral necrosis after long cold ischemia is demonstrated, but the material is too small to permit conclusive evidence on this point.
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