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Femoral artery pressure (FAP) measurements were carried out to evaluate the hemodynamic significance of aorto-iliac occlusive disease in 150 patients (173 limbs) at the time of transfemoral angiography. Clinical assessment based upon traditional criteria of claudication level, pulse examination, and monoplane angiography were at variance with the results of this physiologic testing in approximately one-third of the patients. Results were most variable, and FAP testing most helful in evaluating patients with moderate diffuse disease on angiography, who are usually difficult to evaluate clinically. Strong correlation existed between FAP evaluation and the results of arterial reconstructive surgery. Of the patients with a positive FAP result who underwent proximal vascular reconstruction, 96% had satisfactory relief of ischemic symptoms despite uncorrected distal disease in the majority. In contrast, 57% of the patients undergoing proximal operation despite a normal FAP result were unrelieved of symptoms and required subsequent distal procedures. Similar correlation existed with results of femoro-popliteal and femoro-femoral grafting. This simple physiologic test has been found of great value in selecting the proper level of arterial reconstruction and in accurately predicting the results of surgery.

A review of 24,000 consecutive autopsies during a 23-year period from 1952 through 1975 at the Massachusetts General Hospital revealed 473 patients died with surgically intact arteriosclerotic abdominal aortic aneurysms (AAA). Contrary to previous studies, the incidence of rupture of AAA between 4 and 7 cm in our experience is similar and significant (25%). The location of rupture and duration of symptoms were recorded. Of the multiple-risk factors considered, only size seemed to bear on the likelihood of AAA rupture. Of 52 patients followed 3 months to 10 years before death with known AAA, the majority died of the ruptured AAA. In a surgical environment with an expected mortality of less than 2%, even small aortic aneurysms should be resected.

This is a resource and planning guideline for hospitals and physicians. The status of medical instrumentation in peripheral vascular disease diagnosis is reviewed and the application of examination methods to categories of vascular disease discussed. Resour

Proper clinical management of a patient found to have an asymptomatic carotid bruit continues to be controversial, with wide differences of opinion concerning the advisability of angiography and surgery. A noninvasive cerebrovascular evaluation is described, which combines three separate but complimentary procedures: ocular pneumoplethysmography (OPPG), carotid audiofrequency analysis (CAA), and cerebral Doppler analysis. Such studies are particularly helpful in evaluating patients with an asymptomatic carotid bruit. The reliability and effectiveness of this approach was evaluated in a series of 165 consecutive patients with an asymptomatic bruit. Angiography was recommended in patients with positive results (42%) and safely withheld in those with negative findings (58%). There were two false-positive results and only one known false-negative interpretation.

Because of the importance of size in the decision for elective operation in patients with abdominal aortic aneurysm (AAA) and the need to identify accurately even small aneurysms, a prospective study was carried out to compare currently available diagnostic methods. A series of 78 patients with AAA underwent evaluation by physical examination, lateral lumbar spine X-ray, aortic ultrasound, and aortography. Measurements were compared to aneurysm size at operation. Physical examination was most variable, and tended to overestimate size by approximately 20%. Lateral spine X-ray was useful in three of every four patients and in these cases it was reliable and reasonably accurate. Ultrasonography was most widely applicable and very reliable for diagnosis. Its tendency to underestimate aneurysm size in our experience may be improved by use of gray-scale units, which better define aneurysm wall thickness. The anatomic information provided by aortography was of great value in the surgical management of patients with AAA, but aortography was of limited value in accurate measurement and should not be employed for this purpose.

Hemodynamic measurements were performed and ECG recorded before and shortly after infrarenal aortic cross-clamping during operation for abdominal aortic aneurysm in five patients without evidence of heart disease (group I) and in ten patients with severe coronary artery disease (group II). All patients sustained an increase in systemic arterial pressure. Group I demonstrated a decrease in pulmonary artery, pulmonary capillary wedge (PCW), and central venous pressures when the aorta was clamped, whereas group II demonstrated an increase. The difference in response of the groups is significant (P less than 0.05). All three patients who responded to cross-clamping with increases of 7 mm Hg or greater in PCW demonstrated myocardial ischemia during cross-clamping. None of the values measured prior to cross-clamping predicted with certainty the response to cross-clamping. Sodium nitroprusside reversed the elevation of left ventricular filling pressure in all three patients, and in two patients, relieved evidence of myocardial ischemia concurrently. In the third patient, ventricular irritability was abolished by lidocaine and did not recur. We conclude that infrarenal aortic cross-clamping may cause myocardial ischemia in patients with severe coronary artery disease. This ischemia may be predicted by a rise in PCW at the time of cross-clamping, and vasodilator therapy is indicated in such patients.

Continuous electroencephalographic (EEG) monitoring has been generally accepted as the most sensitive detector of cerebral ischemia and need for an intraluminal shunt during carotid endarterectomy. More recently, internal carotid artery stump pressure has been proposed as a simpler and equally reliable indicator of possible inadequate cerebral perfusion. In this study, stump pressure measurements and EEG changes were compared in 80 carotid endarterectomies. The mean stump pressure for patients with ischemic EEG changes was 58 mm Hg, vs 66 mm Hg for those without EEG alterations (not statistically significant). Eleven of 17 patients with definite ischemic EEG changes had stump pressure greater than 59 mm Hg, a value generally equated with adequate cerebral perfusion. EEG interpretations and stump pressure predictions did not agree in 18 of 80 patients (22.5%). Stump pressure measurements should be used with caution as the sole monitor of cerebral ischemia and need for intraluminal shunting.