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Background: Accurate determination of progression of lower-extremity arterial occlusive disease (LEAOD) is required for natural history studies and evaluation of therapies for atherosclerosis. Objective: To determine if changes in the anklebrachial index (ABI) correlated with progression of LEAOD as determined by arteriography or duplex scanning. Design: In patients with prior suprainguinal or infrainguinal lower-extremity revascularization, progression of LEAOD in native arteries was determined by comparing a preoperative (baseline) arteriogram with late follow-up arteriography or duplex scanning. Superficial femoral and popliteal arteries were graded as having less than 50% stenosis, 50% to 99% stenosis, or as being occluded. Tibial arteries were graded as continuously patent or occluded. Operated and nonoperated extremities were included in the study. The baseline ABI was performed postoperatively and repeated at follow-up arteriography or duplex scanning. Progression of LEAOD by the ABI was defined as a decrease in the ABI of 0.15 or greater. Progression of LEAOD by imaging studies was defined as an increase in 1 category of stenosis. Extremities with suprasystolic pressures were excluded. Setting: Tertiary vascular surgical service. Extremities and Patients: One hundred ninety-three extremities were studied in 114 patients during a mean follow-up of 3.3 years. Results: Seventy-two lower extremities (37.3%) showed progression of atherosclerosis by late follow-up arteriography or duplex scanning. Using the imaging studies as the criterion standard, the ABI had 102 true negatives, 29 true positives, 42 false negatives, and 20 false positives (sensitivity, 41%; specificity, 84%; positive predictive value, 59%; negative predictive value, 71%; and accuracy, 68%) for determining the progression of LEAOD. Conclusions: The ABI is relatively insensitive in identifying the progression of LEAOD as demonstrated by the use of imaging studies. In studies of natural history or therapy for atherosclerosis, imaging studies should be used in preference to the ABI to evaluate the progression of LEAOD accurately. Arch Surg. 1997;132:836-841

Objective: To describe our experience with surgical therapy for upper extremity ischemia incident to emboli from aneurysms of the subclavian artery. Design: Retrospective review case series. Setting: Vascular surgery practice at a university hospital-based tertiary referral center. Patients: All patients treated for upper extremity ischemia caused by embolism from a subclavian artery aneurysm from January 1, 1990, to July 31, 1996. Intervention: All patients underwent detailed history and physical examination, screening for immunologic and hypercoaguable disorders, noninvasive vascular laboratory evaluation, and arteriography of the aortic arch in both arms and hands. Surgical treatment consisted of rib excision or fracture plating, aneurysm excision, and interposition vein grafting, with additional saphenous vein bypasses to brachial or forearm arteries as needed to provide uninterrupted circulation to the wrist. Results: Twelve patients (6 males; mean age, 37 years) were treated. All had episodic upper extremity ischemia with an initial misdiagnosis of primary vasospastic disorder. Rest pain and/or ischemic ulceration developed in 3. Duration of symptoms before correct diagnosis averaged 7 months (range, 1-36 months). All patients had bony abnormalities of the thoracic outlet (8 cervical ribs, 3 abnormal first ribs, and 1 unstable clavicular fracture). All aneurysms contained intraluminal thrombus, and all patients had multiple ipsilateral distal arm, forearm, and/or hand arterial occlusions indicating chronic and repeated embolization. All patients underwent aneurysm excision and interposition vein grafting, with additional vein bypass to the brachial (3 patients) and/or forearm arteries (5 patients). Mean follow-up was 18 months (range, 2 weeks to 63 months). Eleven patients had complete symptomatic relief, and 1 patient improved. All subclavian interposition grafts remained patent. Two distal bypass grafts occluded in patients with preoperative arteriograms demonstrating no patent forearm arteries. There has been no limb loss. Conclusions: Hand ischemia caused by embolization from a subclavian artery aneurysm occurs in young patients without atherosclerosis and is frequently misdiagnosed as vasospasm. Despite advanced disease and multiple chronic distal arterial occlusions, surgical treatment by resection of bony abnormalities, aneurysm excision and grafting, and distal bypass grafting produces excellent results. Arch Surg. 1997;132:527-532

Objective: To determine if peroneal bypass is a suitable alternative to inframalleolar bypass in patients with ischemic pedal gangrene. Design: Review of a prospectively acquired vascular registry. Setting: University practice limited to vascular surgery. Patients: Patients with chronic lower-extremity ischemia and pedal gangrene evaluated between 1985 and 1995 in whom the only options for arterial reconstruction were bypass to the peroneal or an inframalleolar artery. Interventions: Peroneal or inframalleolar reverse vein bypass. Main Outcome Measures: Time to healing and life-table analyses of survival, primary patency, and limb salvage. Results: Eighty-three peroneal and 46 pedal bypasses were performed for ischemic foot gangrene. The groups were equivalent for sex, diabetes mellitus, heart disease, hypertension, renal failure, hypercoagulable states, previous ipsilateral bypass, smoking, and preoperative ankle-brachial indices. Patients with inframalleolar bypass were younger than patients with peroneal bypass (63.9 vs 71.6 years, P =.005) and had higher postoperative ankle-brachial indices (1.02 vs 0.91, P =.004). However, 3-year survival rates (69.1% inframalleolar vs 60.0% peroneal, P =.35), limb salvage rates at 2 years (70.3% vs 85.8%, P =.10), and time to wound healing (19.7 vs 21.6 weeks, P =.66) were equivalent. Conclusion: Peroneal and inframalleolar bypass for ischemic pedal gangrene have equivalent intermediateterm survival, limb salvage, and wound healing. Surgeons should not feel obliged to perform inframalleolar bypass for pedal gangrene if peroneal bypass is possible. Arch Surg. 1996;131:894-899

Since 1980, 498 patients with 627 critically ischemic legs (rest pain, gangrene, ischemic ulcer, and ankle-brachial pressure index less than 0.40) were treated with revascularization regardless of operative risk or anticipated operative difficulty. Primary amputation was performed only when no graftable distal vessels were present (14 primary amputations [2.8%]) or in neurologically impaired, hopelessly nonambulatory patients. The mortality for revascularization was 2.3%, and the median hospital stay was 11 days. During follow-up, 41 limbs (7%) required amputation, 31 after failure of revascularization and 10 despite patent revascularizations. Renal failure had an adverse influence on limb salvage (67%) because of a significantly increased requirement for amputation despite patent revascularizations. We conclude aggressive limb revascularization in patients with critical lower-extremity ischemia results in low operative morbidity and mortality and excellent long-term limb salvage. Patients with critical leg ischemia and renal failure are at higher risk for limb loss than patients without renal failure.

• During the past eight years, we performed 312 lowerextremity amputations for ischemia. Amputation requiring no prosthesis was achieved in 31% of patients, knee joint preservation in 72%, and overall primary amputation healing in 75%. Amputation mortality was 6%. The use of prior arterial reconstruction, careful wound care, and willingness to accept nonhealing of trial amputations were important factors in obtaining the most distal possible healed amputation. An accurate evaluation of the impact of new methods of selecting amputation level and evaluating amputation results can only be achieved by a report of the total institutional amputation experience, not by reports of a single type of amputation. (Arch Surg116:89-92, 1981)

ALTHOUGH aneurysms of the abdominal aorta and iliac arteries have received much attention in recent years, very little has been written about hypogastric artery aneurysms. A recent experience with a patient who had rectal, urethral, and ureteral obstruction from a large hypogastric artery aneurysm prompted this review. A review of 671 hospital records containing the diagnosis of aortic or iliac artery aneurysm, or both, disclosed only three cases of isolated hypogastric artery aneurysms. One of these patients has been studied and treated by the authors. His case will be presented in detail, and the other two cases will be briefly presented. Report of Cases Case 1. —An 86-year-old white man had a six-month history of increasing difficulty with urination and bowel movements. He had noted frequency, hesitancy, intermittency, dribbling, strangury, and nocturia two to three times. He had also noted abdominal fullness, flatulence, increasing difficulty with bowel movements, and intermittent