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Phlegmasia cerulea dolens (PCD) is a rare venous disorder that continues to be a major therapeutic challenge. We reviewed 16 cases of PCD treated during the past 15 years; 11 of the patients were male, and the average age of all the patients was 59 years. Malignant disease was the most common underlying condition (seven patients). Venous gangrene (VG) was present in seven extremities. Three treatment methods were used alone or in combination--intravenous heparin, venous thrombectomy, and thrombolytic therapy. Heparin was used initially in 13 patients; it yielded a successful result in seven (53%) patients, none of whom had VG. Venous thrombectomy was done in six patients; in three it was the primary procedure, in two it followed failure of heparin, and in one it followed failure of both heparin and thrombolytic therapy. Venous thrombectomy was successful in three (50%) patients, one of whom had early VG. Thrombolytic therapy was used on one occasion in conjunction with both heparin and venous thrombectomy, without benefit. Five patients died, all with VG, three after heparin only, one after heparin and venous thrombectomy, and one after all three treatment methods. Review of the 38 cases reported in the recent literature shows comparable results. These data suggest that nongangrenous forms of PCD respond well to systemic anticoagulation. Combination therapy using venous thrombectomy and heparin is indicated for severe ischemia, early VG, or failure of PCD to improve after six to 12 hours of heparin therapy. Phlegmasia cerulea dolens with VG is the lethal form of the entity and responds poorly to established therapy. Future therapeutic trials need to consider aggressive use of thrombolysis with or without thrombectomy.

From 1975 to 1988, 25 patients with a vertebral artery (VA) injury were treated. Admission neurologic status was intact in 14 patients (56 percent). Eight patients had deficits due to direct nerve or spinal cord injury, two patients had symptoms referable to vertebrobasilar ischemia, and one patient had a contralateral deficit due to an associated carotid artery injury. Twenty-two of 25 patients (88 percent) underwent diagnostic arteriography. Twelve patients (48 percent) with 9 occlusive and 3 minimal injuries were observed. Seven patients (28 percent), three with exsanguinating hemorrhage, were treated by operative exploration and VA ligation. Six patients (24 percent), two with a VA pseudoaneurysm and four with an arteriovenous fistula, were managed by percutaneous transcatheter embolization. The neurologic status was unchanged or improved in 22 patients (88 percent) at discharge. Two patients developed Horner's syndrome after VA ligation. Transient posterior circulation ischemia occurred in a single patient after percutaneous transcatheter embolization. There was no mortality. The majority of VA injuries are best managed by nonoperative methods. Untoward neurologic sequelae are rare. Operative intervention and VA ligation should be reserved for patients with active hemorrhage or large pseudoaneurysms and arteriovenous fistulas which cannot be embolized.

Ex vivo renal artery surgery has been reported by several investigators and has extended the role of revascularization in the treatment of lesions previously managed by nephrectomy alone. Several techniques are available for use, and selection of the most appropriate method can be tailored to the specific anatomy being managed. Our total experience included 27 kidneys that have been managed by ex vivo renal artery reconstruction. Lesions managed in this manner include two kidneys with renal artery stenosis and renal tumors, one kidney with a congenital branch arteriovenous malformation, and 24 kidneys with branch occlusive or aneurysmal disease from fibromuscular dysplasia. Postoperative angiography was performed in 22 cases and defined successful revascularization without technical error in 20 cases. One operative death occurred as a result of myocardial infarction. One patient required reoperation to control bleeding, and two patients had temporary acute tubular necrosis during the postoperative period. Techniques employed included ex vivo repair with autotransplantation to the iliac system (six kidneys), mobilization and perfusion without transection of the renal vein (10 kidneys), and ex vivo perfusion and repair with replacement into the original renal fossa (11 kidneys). The authors believe this latter technique of reconstruction to be preferable to autotransplantation for the usual patient undergoing ex vivo repair of complex renovascular lesions.

The outcome of 80 patients with 85 penetrating injuries to the extracranial carotid artery (CA) were analyzed after three types of treatment: (1) 54 patients, 17 with a neurologic deficit, who underwent arterial reconstruction; (2) 18 patients, eight with a neurologic deficit, who had CA ligation or non-operative management of a CA occlusion; and (3) eight patients, two with a deficit, who had minimal nonocclusive injuries managed nonoperatively. Outcome was analyzed using a Carotid Neurologic Score (CNS). The CNS is a quantitative measure of neurologic outcome and survival and ranges from -1 to +3. The higher the CNS, the more favorable the outcome. The conditions of nine patients in group 1 neurologically improved after treatment, 41 were the same, and four were worse. Forty-four patients were neurologically intact and three died. The mean (+/- SD) CNS was 1.9 +/- 0.8. In group 2, one patient's condition improved, 13 stayed the same, and four deteriorated. Ten patients were intact and two died. The mean CNS was 1.3 +/- 1.13. In group 3, two patients' conditions improved and six stayed the same. All eight patients were intact; there were no deaths. The mean CNS was 2.3 +/- 0.35. There was a significantly higher CNS for groups 1 and 3 compared with group 2. The CNSs of groups 1 and 3 were not significantly different. Arterial reconstruction provides the best outcome for all penetrating CA injuries except nonocclusive limited intimal injuries that require only observation.

The role of balloon catheter femoropopliteal percutaneous transluminal angioplasty (FP PTA) continues to be controversial 14 years after its initial description. In high-risk patients with limb-threatening ischemia, the role of FP PTA is unknown. We reviewed the cases of 27 patients in whom high operative risk and advanced ischemia resulted in referral for PTA of the femoropopliteal segment. Technical and hemodynamic success rates were 74% and 52%, respectively. Patient follow-up was 3 to 84 months after PTA (mean 24 months). Nine patients (33%) had successful limb salvage for more than 12 months. The cumulative limb salvage rate was 47% at 2 years. Established prognostic criteria did not predict this subset of patients. Hemodynamic improvement after PTA did correlate closely with both early and late successful limb salvage. There were two periprocedural deaths. Morbidity included an acute arterial occlusion necessitating an emergency FP bypass and two minor complications. FP PTA is useful in selected high-risk patients with limb-threatening ischemia. Protocols to facilitate successful long-term limb salvage must include close liaison between the vascular surgeon and interventional radiologist, intensive periprocedural monitoring, and serial noninvasive hemodynamic assessment.

A 17-year study has been made of 63 patients who had a variety of colonic disorders treated by total abdominal colectomy with ileorectal anastomosis in four hospitals affiliated with Vanderbilt University. Forty-three of these patients made an uneventful recovery, but 20 others sustained significant complications, nine of which proved to be fatal (hospital mortality rate, 14%). The study shows (and confirms the work of others) that ileorectal anastomosis after total abdominal colectomy is a reasonable procedure that provides satisfactory results on a long-term basis in a majority of patients when strict criteria in patient selection are followed in its application.

In a previous study the authors reported greater endothelialization and thrombus-free surface area in albumin-coated grafts compared with collagen-coated grafts after 1 month's aortic interposition. Another study was undertaken to determine whether these differences persisted after a 6-month implantation period. A 6 cm segment of either an albumin-coated [n = 6] or a collagen-coated [n = 4] graft was implanted into a canine descending thoracic aorta for 6 months. Light micrographs from multiple sections of each explanted graft were scored from 1 to 4, least to most, for tissue ingrowth, perigraft inflammation, and capsular thickness. Using computer planimetry, luminal thrombus free surface area and endothelial coverage were calculated from gross and electron photomicrographs, respectively. The results were averaged and expressed as mean +/- standard error (SEM). After 6 months, no significant differences were noted between the albumin-coated grafts and the collagen-coated grafts, both of which were durable and served equally well as scaffolds for vascular remodeling and tissue incorporation. The authors conclude that the safety, ease of handling, low porosity, low thrombogenicity, and durability of the albuminated grafts warrant their clinical trial.

An in vitro cytotoxicity assay for cyclophosphamide metabolites in rat body fluids is described. Of the two tissue culture tumor cell lines employed, the Walker-256 rat carcinosarcoma was more sensitive to metabolite levels than the L-1210 mouse lymphocytic leukemia. The Walker-256 system detected cyclophosphamide metabolite levels two orders of magnitude lower than the commonly used 4-(p-nitrobenzyl)pyridine analytical procedure.

A mutant of Euglena gracilis Z is described that spontaneously produces irreversibly bleached mutants at a high frequency. Bleaching only occurs during exponential growth under highly aerobic conditions. The kinetics for bleaching and growth of bleached and nonbleached cells suggest that mutation is induced by segregation of a cellular component that becomes limiting after several culture generations. The properties of spontaneous bleaching closely resemble the properties of induced organelle mutagenesis in E. gracilis and yeast.

Severe occlusive disease of the carotid artery may produce a rare syndrome of chronic ocular ischemia. Prolonged retinal hypoxia is associated with characteristic funduscopic changes and neovascularization of the iris, with subsequent obstruction of aqueous humor resorption. A case of neovascular glaucoma as a result of severe bilateral carotid occlusive disease and the pathophysiology involved are discussed. Definitive treatment consisted of carotid endarterectomy and aggressive control of intraocular pressure, including operative placement of a drainage implant in the anterior chamber of the eye. Seizure activity and an exacerbation of glaucoma developed after successful revascularization, exemplifying the derangements in cerebral and ocular function that may result from chronic hypoperfusion.