Letter to the Editor re EJVES2863.
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Humans↗
Biomedical subjects
M Enzler
Publications and source records attributed to M Enzler.
The long-term mobility and mortality of patients with peripheral arterial disease following bilateral amputation.
OBJECTIVES: To study the postoperative course, mobility, housing conditions and the mortality following bilateral amputations in patients with peripheral arterial occlusive disease (PAD). DESIGN: Part retrospective, part prospective open study. SETTING: Vascular unit of a university hospital. PATIENTS: Sixty-six consecutive patients with PAD undergoing bilateral trans-metatarsal (TM), below-knee, through-knee and above-knee amputations between 1980 and 1989 were studied. Their medium are at the time of an amputation in the second limb was 58 years (range 27-91 years). CHIEF OUTCOME MEASURES: Initial and subsequent amputation levels, co-morbidity, mobility, housing conditions and mortality were recorded from 1989 until 2001. MAIN RESULTS: Follow-up was 98%. Hospital mortality after amputation of the second leg was 12%. The mortality after 2 years was 38% and after 5 years 69%. At the end of the observation period, truly three patients were still alive (15%). Coronary heart disease was the leading cause of death and accounted for 37%, cerebro-vascular incidents for 14%. During follow-up, 56% of the patients needed at least one stump revision or reamputation to a higher level. Reamputations occurred after TM in 63%, below-knee in 42% and/through-knee amputations in 69%, respectively. Of 58 patients who were discharged, 38% became able to walk, 52% were mobile with a wheelchair and 10% remained bedridden. Of the patients who were able to walk, 82% returned to individual homes as compared to 63% of those who were mobile with a wheelchair. CONCLUSIONS: Amputation levels should be kept as distal as possible in the interest of mobility which is one of the primary keys to social reintegration. However reamputations to higher levels are frequent as PAD progresses. The well-known very high mortality is clearly related to generalised atherosclerosis.
Adult↗
Inguinal mass as a late complication of hip arthroplasty. Differential diagnosis and treatment from a vascular surgical perspective.
We report on three patients with a symptomatic inguinal mass as a late complication of repetitive arthroplastic hip surgery. In one case, there was a false aneurysm and in two cases a so-called "synovial cyst". A synovial cyst is usually an enlarged iliopsoas bursa in communication with the capsule of the hip joint. Hypersecretion in arthritic joints may cause expansion of this bursa. Compression of the common femoral and external iliac veins may lead to outflow obstruction and leg swelling. The most important diagnostic tools are plain films of the hip joint and ultrasound of the groin including colour-coded assessment of the femoral vessels. Symptomatic cysts usually need removing by an anterior approach. Loose arthroplastic components can be causative and should be replaced.
Adult↗
Spontaneous reversibility of early reobstruction following percutaneous transluminal angioplasty.
Early reocclusion and late restenosis are well-known problems after percutaneous transluminal angioplasty (PTA). We report here on a phenomenon not described so far in two patients with peripheral arterial occlusive disease who had PTA of the common iliac and the superficial femoral artery, respectively. Both had a good hemodynamic and clinical initial result. However, within two days after PTA symptomatic reobstruction occurred documented by noninvasive measurements. Noteworthy, this reobstruction was spontaneously reversible within days. The possible pathomechanism is discussed.
Angiography↗
A soft popliteal mass and pulmonary embolism.
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Aneurysm↗
Osteomyelitis of the pubis following suspension of the neck of the bladder with use of bone anchors. A report of four cases.
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Aged↗
[Bypass to the anterior interosseous artery of the arm: follow-up of 3 years].
Bypass to the anterior interosseous artery in the forearm: Follow-up at 3 years A 56 year-old, otherwise healthy woman suffered from acute ischaemia of her left arm one year after a fracture of the radius which had been treated with plaster fixation. Angiography demonstrated occlusions of the brachial, radial and ulnar arteries. Three surgical thrombectomies, local fibrinolysis and throacoscopic sympathectomy all failed to restore adequate blood supply to the forearm and hand. The patient continued to have pain on exercise and even at rest. After three months, an autologous vein bypass graft was implanted from the proximal brachial artery to the anterior interosseous artery. Thereafter, the patient became free of symptoms. At over three years, angiography was repeated and demonstrated a patent bypass. Furthermore, the lumen of the previously heavily diseased brachial artery had considerably improved in terms of diameter and regularity. These changes and possible mechanisms are discussed.
Angiography↗
Surgical approach in the treatment of arterial aneurysms associated with Behçet's disease.
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Adult↗
Successful treatment of an extended leg ulcer in systemic sclerosis.
We report the successful surgical treatment of a large and painful leg ulcer associated with systemic sclerosis (scleroderma). In addition, there was a long occlusion of the superficial femoral artery, and ankle systolic blood pressure was 80 mmHg (ankle-brachial-index 0.65). All conservative treatments including systemic antibiotics, nifedipine, intravenous iloprost, intravenous penicilline G and hyperbaric oxygen failed. Pain was intolerable and below-knee amputation was considered. In a first attempt to save the limb, the patient underwent femoropopliteal bypass surgery. Despite a successful outcome of the bypass operation and normalization of the ankle blood pressure, the large wound remained recalcitrant and extremely painful. A second attempt to save the limb consisted of complete debridement of all sclerotic tissue down to the fascia and split skin grafting. The graft took in over 90% of the surface and the remaining wound healed spontaneously. Large leg ulcers in systemic sclerosis can become limb threatening. Radical debridement combined with a split skin graft seems to be a promising way to avoid amputation.
Aged↗
[Bouveret syndrome--a rare gallstone complication].
A 62 year old woman presented with the symptoms of a gastric outlet obstruction together with severe metabolic hypochloremic alcalosis. A gallstone in the duodenum with gastric outlet obstruction was diagnosed by abdominal ultrasonography. In a one-stage surgical procedure, cholecystectomy, enterolithotomy and repair of the cholecytoduodenal fistula were performed. The postoperative course was uneventful. Pathogenesis, clinical findings, diagnostic procedures and therapeutic options of gastric outlet obstruction secondary to a gallstone impacted in the duodenal bulb (Bouveret's Syndrome) are discussed.
Alkalosis↗
[Quality control in peripheral vascular surgery].
Indications and modalities of quality control in infrainguinal bypass surgery are reviewed and discussed. A concept and an armamentarium for its practical use are presented. The majority of graft occlusions occur during the first postoperative year. Most failures in the first month are due to technical errors. Many of these can be detected by intraoperative completion control, and immediately repaired. This contributes to improved graft patency rates. In the further course, myo-intimal hyperplasia accounts for most graft stenoses and occlusions. If stenoses are detected and dilated before occlusion occurs, long-term patency is but little impaired. Conversely, patency rates are clearly inferior in grafts following thrombectomy or thrombolysis. Therefore, identification of failing grafts and avoidance of failure are the objectives of surveillance. We have followed routinely a surveillance program since 1991. During surgery, grafts were controlled by completion angiography. Arterial pressures were measured and the ankle-brachial index calculated postoperatively and 1, 3, 6 and 12 months after surgery. In addition, a number of grafts were followed by duplex sonography. Data were stored in an electronic data base featuring several interactive functions. E.g., ankle-brachial and duplex-sonography indices were calculated and rated automatically according to current criteria. Secondary patency after 18 months was 86 per cent in suprageniculate femoro-popliteal bypass grafts, 84 per cent in infrageniculate and 65 per cent in crural (n = 19/23/27).
Blood Vessel Prosthesis↗
[Standardized follow-up after peripheral bypass operation].
We present a standard protocol of postoperative controls designed for early recognition of possible stenosis or graft failures after peripheral bypass operations. This protocol includes: a) angiography during the first week after surgery, b) clinical and Doppler-pressure measurement 1, 3, 6 and 12 months after surgery. 53 patients with 62 peripheral bypasses were followed. The cumulative patency rate was 87.5% after 12 months.
Aftercare↗
[Functional therapy of Achilles tendon rupture].
We are going to present two cases with functional treatment of Achilles tendon ruptures. We define a treatment as functional if the involved limb is either not immobilized at all or whenever the immobilization is incomplete and for a limited time only and when no operation is necessary. The functional treatment is presented as an alternative, and we are going to present the advantage and disadvantage.
Achilles Tendon↗
[Misinterpretations in arteriography of the lower extremities].
Arteriography is still the most important diagnostic tool in the assessment of chronic lower limb ischemia. Unfortunately, demonstration of distal vessels is often poor. Inadequate arteriography makes decisions on the feasibility and the site of reconstruction impossible. Methods to improve the quality of arteriograms include correct positioning of the legs in internal rotation, long exposure times, additional lateral views and the capacity of digital subtraction. The importance of positioning the legs in internal rotation is illustrated by several examples.
Angiography↗
[Indications, technique and interpretation of arterial Doppler ultrasound].
Doppler sonography is one of the most important diagnostic tools for angiologists and vascular surgeons, and also for general practitioners with an interest in vascular disease. It can be carried out easily and at low cost and at the same time provides reproducible, quantitative data on with further diagnostic and therapeutic decisions can be based. First, systolic arterial pressure in the anterior and posterior tibial and in the peroneal arteries are measured, with the Doppler probe placed at ankle level. A cuff is wrapped around the lower leg and inflated until the Doppler signal disappears and then deflated. The highest value measured in each leg is termed "ankle pressure". Division of the latter by systolic brachial pressure results in the so-called "ankle-brachial-index" or "ABI". Ankle pressure and ABI correlate well with clinical findings. In normal individuals, the ABI is greater than 1. In claudicators, it ranges between 0.3 and 0.9, in patients with resting pain between 0.1 and 0.5 and with ischemic tissue loss between 0.0 and 0.2. After angioplastic or surgical revascularisation procedures, a fall of the ABI by 0.15 or more is an indication of relevant hemodynamic deterioration and therefore calls for further investigation by arteriography or colour duplex sonography.
Arterial Occlusive Diseases↗
[Differential diagnosis of ischemia of the lower extremities in young adults].
Lower-extremity arterial occlusive disease in individuals younger than 50 years is rare. We report on 4 young adults with lower limb ischemia, each of them with a different cause. According to literature premature atherosclerosis is the most common cause and is followed by thromboangiitis obliterans, coagulation abnormalities and popliteal artery entrapment syndrome. We suggest a diagnostic concept which could help to avoid undue delay.
Adult↗
[Proximo-distal course of the diameter of the great saphenous vein and distribution of the number of side branches as an inherent difficulty in infra-inguinal arterial in situ bypass].
The greater saphenous vein is still the best material for infrainguinal arterial bypasses, particularly if they have an infrapopliteal distal anastomosis. Although a lot of advantages have been presumed for the in-situ bypass, the reported results are not significantly better than with the reversed technique. To find some additional explanations, we studied post mortem the anatomy of 20 greater saphenous veins with regard to the diameter and the number of side branches and compared the results with 10 phlebographies. A minimal diameter (2.6 mm) and a maximum of side branches and venous valves were found at the proximal calf. Furthermore, this region was characterized by a lot of anatomic variants such as double systems (25%) or cross over variants (5%). These findings are surgically relevant and may reduce the bypass patency: 1. There is an increased hemodynamic resistance in longer bypasses, 2. The small diameter (particularly if smaller than 2 mm) means a risk for the patency of the distal anastomosis, 3. The high frequency of side branches requires a comparable exposition of the GSV as for the reversed technique, 4. The introduction of the valvulotomy from distally may overestimate the proximal diameter and underestimate the frequency of variants and may therefore cause significant endothelial damages or even perforation.
Humans↗
[Recurrent acute occlusions of the popliteal artery before age 50: popliteal entrapment syndrome?].
Compression of the popliteal artery by the medial head of the gastrocnemius muscle is termed "Popliteal Artery Entrapment". The anatomical course of the artery can be normal or abnormal. The entrapment can cause occlusion of the artery or peripheral embolism. This syndrome is an important differential diagnosis in younger patients with recurrent peripheral arterial ischemia. Diagnosis is made by history, clinical findings, arteriography and CT-scan of the knees. All cases of popliteal artery entrapment, whether the artery is occluded or not, should be operated on.
Adult↗