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In severe traumatic injuries to the lower extremity, it is often a difficult decision to attempt heroic efforts aimed at limb salvage or to amputate primarily. To answer this question, the authors performed a 5-year review of 70 limbs in 67 patients. Patients were identified as presenting with major lower extremity trauma and an associated arterial injury. Nineteen (27%) of the 70 limbs were amputated. Limb salvage was not related to the presence or absence of shock and order of repair (orthopedic or vascular). No statistical difference was noted between the time of injury to operative repair in either the amputated or limb salvage group. Limb salvage was related to warm ischemia time and the quantitative degree of arterial, nerve, bone, muscle, skin, and venous injury. A limb salvage index (LSI) was formulated based on the degree of injury to these systems. All 51 patients with an LSI score of less than 6 had successful limb salvage (p less than 0.001). All 19 patients with an LSI score of 6 or greater had amputations (p less than 0.001). Although statistics cannot replace clinical judgment, this index can be a valuable objective tool in the evaluation of the patient with a severely traumatized extremity.

The Syme amputation is an old operation that has been used during this century primarily as a means of treating traumatic injuries to the forefoot in military patients. In 1984 we made a deliberate attempt to perform the operation in a highly selective group of dysvascular patients with forefoot necrosis who happened to have a palpable posterior tibial pulse. We reviewed the charts of 26 patients who underwent a one-stage (3 patients) or two-stage (23 patients) Syme amputation. The mean age was 60 years, (range 32 to 74 years). There were 17 insulin-dependent diabetic patients, and 3 diet-controlled diabetic patients. Twenty-two patients (85%) had a palpable posterior tibial pulse before surgery. Fourteen patients (54%) underwent a preliminary Ray (4) or transmetatarsal (10) amputation to rid the forefoot of an active infection. Overall, 20 patients (77%) had successful Syme amputations. Nineteen of 22 patients (85%) with a palpable posterior tibial pulse had a successful amputation in contrast to one out of four patients (25%) who did not have a palpable pulse before surgery (p = 0.04). The mean follow-up of all patients was 23 months. The durability of the operation was demonstrated in finding that only one patient in 20 initially successful Syme amputations required revision to the below-knee level. The two-stage Syme amputation can be a very gratifying operation with success rates approaching 85%, even if offered to elderly diabetic patients. The single most important feature for success is to limit the operation to those patients with a palpable posterior tibial pulse before operation.

Thirty-eight hip disarticulations performed in 34 patients were retrospectively reviewed. The indications were ischemia secondary to atherosclerosis in 17 cases, femoral osteomyelitis in 10, and trauma in 11. Patient ages ranged from 20 to 95 years. The mortality was 60% in patients with ischemia with preoperative infection, 20% in patients with ischemia without preoperative infection, 22% in patients with femoral osteomyelitis, 100% in patients with trauma with preoperative infection, and 33% in patients with trauma without preoperative infection. The overall mortality was 44%. Postoperative wound infections were frequent (63%) and had poor correlation with the presence of a preoperative wound infection. No patient was able to use a prosthesis after hip disarticulation, but most were independent in wheelchairs.

Six patients with unilateral blue toe syndrome presented a diagnostic dilemma with regard to the source of embolization: central aortic versus peripheral. Two patients had moderately severe aortoiliac atherosclerosis associated with focal stenoses in the superficial femoral arteries, and four patients had mild aortoiliac disease associated with localized plaques confined to either the superficial femoral or popliteal arteries. In all patients, it was elected to explore the peripheral lesions first. At operation, ulcerated plaques or focal stenoses were found, and all lesions had adherent white thrombi on their surfaces. All patients were treated either by localized thromboendarterectomy or short reversed saphenous vein grafting. There was no morbidity or mortality. Recurrent embolization did not occur during a follow-up of 8 to 24 months. Distal atherosclerotic lesions should be sought to explain distal embolization before more complex aortoiliac disease is incriminated. In the presence of concomitant aortoiliac disease, it is mandatory to directly explore the peripheral lesion, open the artery, and carefully examine the lesion in situ. Thrombus adherent to the surface of an ulcerated plaque is evidence of an embolizing source. This approach is associated with minimal morbidity and may be curative. If these findings are not present, it would be appropriate to proceed with staged correction of aortoiliac disease.

The origins of historical terms, such as "Arc of Riolan" and "marginal artery of Drummond" are traced herein with emphasis on the inherent confusion caused when these terms are used. Basic mesenteric anatomy is briefly mentioned and pathologic anatomy with its altered direction of blood flow induced by atherosclerosis is stressed. The significance of the meandering mesenteric artery as the main collateral vessel between the superior and inferior mesenteric artery is emphasized along with preoperative and intraoperative ways to ascertain whether or not the origin of this latter vessel can be safely ligated. Specific operations, such as abdominal aortic aneurysmorrhaphy and sigmoid colectomy, which can potentially interfere with blood flow in the meandering mesenteric artery, are discussed in an attempt to prevent postoperative necrosis of any portion of the intestine that may have deficient mesenteric blood flow.

This prospective study examined microbiologic features of arterial tissue and pharmacokinetics and bioactivity of cefamandole and cefazolin in patients undergoing elective primary prosthetic aortoiliofemoral/infrainguinal reconstruction. Double-blind, randomized, perioperative prophylaxis (1 gm intravenously every 6 hours for nine doses) with cefamandole or cefazolin was administered to 47 patients. Specimens of blood serum, subcutaneous fat, thrombus, atheroma, and arterial wall were obtained for culture and minimal inhibitory concentration and drug level analysis by high-pressure liquid chromatography. The serum half-life (hr +/- SEM) was 1.43 +/- 0.36 for cefamandole and 2.22 +/- 0.40 for cefazolin. Over the first 2 hours of surgery and for all time intervals combined, the serum concentration of cefazolin was significantly higher (p less than 0.025) than cefamandole. Irrespective of sampling time, the tissue concentration of cefazolin was significantly greater (p less than 0.005) than cefamandole. Positive arterial tissue cultures were obtained in 12 of 29 patients (41.4%) from 23 of 116 (19.8%) arterial tissue specimens. Coagulase-negative Staphylococcus was the predominant isolate, 64 of 93 (68.8%). Twenty-five of the 51 coagulase-negative staphylocci tested (49%) were slime-producers. During surgery, the arterial tissue concentration of cefamandole fell below the geometric mean minimal inhibitory concentration against all organisms combined, and against S. aureus (with the highest minimal inhibitory concentration of the prevalent isolates), significantly more often than the concentration of cefazolin. The data show that a significant number of primary elective aortoiliofemoral/infrainguinal reconstructions are associated with positive arterial tissue cultures, which represent a potential source of graft infection.(ABSTRACT TRUNCATED AT 250 WORDS)

To assess the need for routine preoperative computerized tomography scanning to discern patients with rupture among those presenting with acutely symptomatic abdominal aortic aneurysms, a retrospective review was performed. During a 5-year period, all patients presenting with symptomatic aneurysm underwent emergency operation without preoperative computerized tomography. The mortality rate was not significantly different among patients with symptomatic, intact aneurysms undergoing emergency operation (3 percent) and those without symptoms having elective operation (5 percent). The mortality rate of patients with ruptured aneurysms was 68 percent. We concluded that the addition of preoperative computerized tomography to the clinical evaluation would not have improved these results. Furthermore, since it is expensive and delays emergency operation in patients with ruptured aneurysms, computerized tomography seems rarely indicated in symptomatic patients with obvious aneurysms.

Twenty-four patients with internal carotid artery lesions extending above the second cervical vertebra underwent mandibular subluxation for additional exposure. The original technique of bilateral arch bar wiring requiring 90 minutes for application has evolved into a circummandibular/transnasal wiring technique requiring approximately 10 minutes. Subluxation of the mandibular condyle 10 to 15 mm anteriorly results in displacement of the mandibular ramus 20 to 30 mm anteriorly. This technique provides a marked increase in exposure of the internal carotid artery up to the base of the skull by transforming a triangular operating field into a rectangular field. The technique is quick, easy to perform, and not associated with objective or subjective temporomandibular joint dysfunction.

During a 4-year period, 136 patients undergoing 152 carotid endarterectomies consented to be randomized to primary or saphenous vein patch closure of the arteriotomy. At operation, before randomization, careful assessment of arterial dimensions and anatomy was made. Patients who had an internal carotid artery (ICA) diameter less than 5 mm, arteriotomy extending more than 3 cm beyond the origin of the ICA, or tortuous or kinked ICAs were not randomized; they received obligatory vein patch closure (necessary in 20% cases). All patients were followed up every 3 months for 1 year and every 6 months thereafter with duplex scanning, ocular pneumoplethysmography, and neurologic assessment. The incidence of atherosclerotic risk factors was equal in the groups and all except one of the patients were male. Perioperative morbidity was not significantly different among those having primary closure (n = 60), saphenous vein patch closure (n = 62), and obligatory vein patch closure (n = 30). Operative time among patients having primary closure (122 +/- 4 minutes) was significantly less (p less than 0.001) than among those having saphenous vein patch closure (150 +/- 3 minutes). Three perioperative strokes were evenly distributed among the groups (2% for all procedures); no deaths and no acute postoperative occlusions occurred. Recurrent disease occurred in 12.9% of patients having saphenous vein patch closure compared with its occurrence in 1.7% of those having primary closure (p less than 0.05). However, most recurrences were moderate stenoses (25% to 50% diameter reduction), all were smooth-surfaced, and none required a second operation. All except one of the recurrences among those patients with saphenous vein patch closure were in the bulb and the origin of the ICA; two had evidence of regression. This finding suggested that thrombus layering in the dilated part of the saphenous vein patch reconstruction was the cause. This study demonstrates that in men with carotid arteries of predetermined minimal dimensions undergoing carotid endarterectomy routine saphenous vein patch closure does not produce superior results, is associated with a higher incidence of early recurrence, and increases operative time. In selected patients with anatomic risk factors for recurrent disease or acute postoperative occlusion, saphenous vein patch closure is appropriate.

We evaluated the accuracy of duplex ultrasound in the postoperative follow-up of patients after renal revascularization. Between May 1976 and December 1987, 125 adult patients underwent 153 renal reconstructive procedures for renovascular occlusive disease. Technically satisfactory duplex scans were obtained in 49 of 59 patients (84%) at an average follow-up of 32 months (maximum 11 years). Arteriograms were available for correlation in 51 arteries or bypasses in 36 patients. Duplex scans accurately classified 8 of 10 stenotic (greater than 60% diameter reduction) or occluded vessels and 36 of 41 patent vessels. The overall diagnostic accuracy was 86%, sensitivity was 80%, and specificity was 87%. We confirmed previous reports that decreased diastolic flow correlated with advanced renal parenchymal dysfunction. We conclude that a normal duplex scan makes it highly unlikely that arteriography will reveal significant recurrent disease. An abnormal duplex scan, particularly in the presence of hypertension or deteriorating renal function, warrants arteriography.

The histopathologic characteristics of primary plaques and recurrent carotid disease were studied in 32 patients. These data were related to symptoms, recurrence interval (6 to 176 months), arteriographic anatomy, and in situ operative findings. A striking predilection was noted for recurrent lesions to be located in the internal carotid artery near the origin, but still within the confines, of the original endarterectomy site and suture line. Although recurrence was frequently associated with a long primary arteriotomy, evidence of technical faults or periarterial fibrosis was rare. Early recurrent lesions (recurrence interval less than 36 months, n = 13) had significantly more smooth muscle cells and proteoglycans (p less than 0.001) than late recurrent lesions (recurrence interval greater than 36 months, n = 19). As previously reported, features of atherosclerosis (abundant collagen, calcium deposits, and foam cells) were more pronounced in late recurrences (p less than 0.001). However, the histopathologic differentiation between early and late recurrent carotid disease was indistinct. A continuum was noted whereby characteristics of late recurrent lesions increased in proportion to recurrence interval. All recurrent lesions were easily distinguished from primary plaques in that recurrences had a less orderly arrangement of all elements and lacked the classic topographic features of advanced atherosclerosis. An important feature that differentiated primary and recurrent lesions was the presence of surface and intraplaque thrombus in 90% of recurrent lesions (p less than 0.001). In early recurrent disease, luminal surface thrombus was striking; this was frequently platelet-rich and showed organization devoid of neovascularity. Intraplaque thrombus was more common in late recurrent disease, consisted almost entirely of fibrin, and was often contiguous with luminal surface thrombus. No discernible relationships were noted between thrombus associated with recurrent lesions and the presence or absence of symptoms, treatment with antiplatelet agents, and hypertension. This finding suggests that thrombus was a continuous and intrinsic component of recurrent disease rather than a secondary, complicating feature. Recurrent carotid disease is a progressive lesion that stems from ongoing thrombogenesis occurring at the endarterectomy site. Organized thrombus and smooth muscle cell proliferation comprise the bulk of the lesion, which undergoes atherosclerotic change with time.

Tuberculous aortitis is a rare entity and its association with necrosis and perforation is even more unusual. Our pulmonary medicine service originally evaluated an elderly woman with a right pleural effusion and upper lobe infiltrate thought to be tuberculosis. An abdominal CT scan performed at that time showed extensive periaortic adenopathy. Isoniazid and rifampin were started, but both were stopped by the patient after less than 6 months of therapy. The patient later had night sweats, a left pleural effusion, and a tender abdominal mass thought to be a symptomatic aneurysm. At operation, the aorta was necrotic and had an inflammatory mass and perforation on the left side. Infrarenal aortic ligation and resection were performed to control infection. A previously placed axillofemoral graft obviated the need for concomitant revascularization. The patient was treated postoperatively with isoniazid and rifampin until hyperbilirubinemia developed, which necessitated alternate therapy with ethambutol and streptomycin. The patient died one month after operation of a presumed pulmonary embolus.

Although the two-stage amputation technique entails an additional operation, several authors have advocated this approach to deal with wet gangrene because it allows primary wound closure with a reduced chance of wound infection. To examine this issue, 47 patients with necrotizing wet gangrene of the foot were randomized prospectively to receive either a one-stage amputation (definitive below- or above-knee amputation with delayed secondary skin closure in 3 to 5 days) or a two-stage amputation (open ankle guillotine amputation followed by definitive, closed below- or above-knee amputation). Antibiotic coverage was standardized with clindamycin and gentamicin used in all patients. Preoperative blood cultures and intraoperative foot cultures were obtained, as well as cultures from the deep muscle and lymphatic area along the saphenous vein to determine the presence of bacteria at the level of initial amputation. Twenty-four patients (11 diabetic and 13 nondiabetic) were randomized to the one-stage procedure. Twenty-three patients (14 diabetic and nine nondiabetic) were randomized to the two-stage procedure. Five of 24 patients in the one-stage group (21%) had positive muscle cultures vs 10 of 23 patients in the two-stage group (43%). Two of 24 patients in the one-stage group (8%) had positive lymphatic cultures vs 7 of 23 patients in the two-stage group (30%). Five of 24 patients in the one-stage group (21%) had wound complications attributable to the amputation technique vs none of 23 patients in the two-stage group (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective study of 76 preoperative patients with aortic aneurysms was undertaken to determine the true incidence of associated disseminated intravascular coagulation (DIC). Although 39% of the patients showed a notable elevation of the fibrin split products level, only three had thrombocytopenia and a clinical bleeding diathesis, as well. Thus, clinically overt DIC occurred preoperatively in only 4% of the patients. All three patients had extensive aneurysms that involved the thoracoabdominal aorta. Preoperative fibrinogen levels in this series tended to be high-normal or elevated and were not good indicators of underlying excessive fibrinolysis. Hemostatic abnormalities, such as ecchymoses and petechiae, may be the key to the clinical diagnosis of DIC in preoperative patients with aortic aneurysms.

Thirteen patients with internal carotid occlusion underwent 14 primary external carotid revascularization procedures over a 31 month period. Ten patients had obliteration of their internal carotid stump combined with patch angioplasty of the external carotid artery, and 3 had vein bypasses from the common carotid artery to the external carotid artery. Eleven patients were symptomatic with either amaurosis fugax or hemispheric transient ischemic attacks. Two patients were asymptomatic. All patients had serial carotid noninvasive tests (B-mode ultrasonography, spectral analysis, and oculoplethysmography). The mean follow-up was 22 months. Recurrent amaurosis fugax secondary to recurrent stenoses developed in two patients. These were correctly predicted by B-mode imaging and altered flow characteristics on spectral analysis. Both patients were successfully treated with reoperative procedures to prevent failure of the primary reconstruction. External carotid revascularization is a safe and durable procedure, but careful periodic follow-up is necessary to detect stenoses developing at or remote from the initial operative site. Carotid noninvasive tests appear to be helpful in detecting recurrent disease. Carotid revascularization is superior to other forms of therapy in patients who have development of neurologic symptoms ipsilateral to a chronically occluded internal carotid artery.