D. C. Berridge

Tissue plasminogen activator in peripheral arterial thrombolysis

Thirty acute peripheral arterial thromboses in 28 patients were treated with local low‐dose intra‐arterial recombinant tissue plasminogen activator (t‐PA). All patients received 0·5 mg h−1 t‐PAand 15 also received 250 units h−1 of intra‐arterial heparin. Overall limb salvage at 30 days was 83 per cent (25 out of 30 limbs). Mean(s.d.) ankle/brachial index was increased by 0·53(0·26) and there was no significant difference between the group receiving t‐PA alone and that receiving t‐PA and heparin. No strokes or major haemorrhages occurred but there were four (13 per cent) minor haematomas associated with the catheter entry site. There were four (13 per cent) deaths from myocardial infarction occurring between 5 and 21 days after treatment. Rethrombosis occurred in four cases (13 per cent). In two patients following t‐PA alone, rethrombosis occurred after 2 and 11 days. Limb salvage was achieved with a successful repeat thrombolysis and a femoropopliteal graft respectively. Rethrombosis after t‐PA and heparin occurred after 30 days in two patients due to poor run‐off and extensive proximal atheromatous disease respectively. t‐FA is a safe, effective thrombolytic agent when given as a low‐dose intra‐arterial infusion. The addition of low‐dose heparin does not produce any significant benefit.

Do preoperative chlorhexidine baths reduce the risk of infection after vascular reconstruction

Pathogenic organisms are frequently present on the skin of vascular patients and are a risk factor for postoperative infection. A randomised trial of preoperative antiseptic baths was performed in 64 high risk vascular patients to determine whether two chlorhexidine baths could reduce the incidence of postoperative sepsis. Although pathogenic organisms were isolated preoperatively in 35% of patients, the wound infection rate after chlorhexidine baths (26%) was greater, though not significantly, than after baths with non-medicated soap (11%). An alternative theory that infection arises via lymphatics in the limb was not confirmed when organisms could not be isolated from groin lymph nodes in a group of 35 patients. The case for preoperative antiseptic regimes in vascular surgery remains unproven.

Intra-arterial thrombolysis using recombinant tissue plasminogen activator (r-TPA): The optimal agent, at the optimal dose?

Thirteen patients received 15 separate courses of intra-arterial (IA) r-TPA for acute and subacute peripheral arterial thromboses. Two patients received second courses: one following rethrombosis 2 weeks after the angioplasty of a residual stenosis, the other following rethrombosis 4 months after the initially successful thrombolysis. There were 10 men and 3 women with a mean age of 75.3 yrs (+/- 12.2). The median duration of ischaemia was 18 days (range 1-60), with five patients having severe ischaemia. All patients received IA r-TPA at a dose of 0.5 mg/h for a mean period of 26.2 hrs (+/- 12.6). Angiographic evidence of lysis was seen in all patients, however, this was insufficient to reperfuse the distal limb in two patients due to absence of run-off. Early rethrombosis occurred in both of these patients (less than 24 hrs, 11 days). There were no major complications, and minor groin haematomata occurred in four patients (three of whom underwent angioplasty). A further two patients rethrombosed despite angioplasty. One was successfully retreated and remains patent 5 months later, the other underwent surgical reconstruction. A partial systemic effect was confirmed by a reduction of plasminogen and fibrinogen to 66% of initial levels, and a reduction of alpha - 2-antiplasmin to 40% of initial levels. Haemoglobin was reduced by a mean 1.28 g/dl (+/- 0.82), however no transfusions were required, and no hypotensive periods occurred. Mean ankle/brachial systolic index (ABSI) was increased by 0.43 (+/- 0.24) overall.(ABSTRACT TRUNCATED AT 250 WORDS)

Screening for clinically unsuspected abdominal aortic aneurysms in patients with peripheral vascular disease

In patients with abdominal aortic aneurysms, most fatalities occur from rupture before the patient can be brought to hospital. Even when seen in hospital the mortality is still approximately 50% in contrast to elective repair which has a substantially reduced mortality of less than 5%. In order to reduce the number of patients dying from rupture, they must be diagnosed early to allow elective intervention, hence there has been considerable renewed interest in screening for abdominal aortic aneurysms. We have studied a consecutive series of 104 patients with either claudication or ischaemic rest pain in the lower limbs to determine the incidence of aortic aneurysms in this type of patient.

A simple technique for thromboembolectomy of the upper limb

Brachial emboli account for only 18% of arterial emboli and present as an uncommon emergency to surgeons. We have examined the route taken and probable outcome of arterial embolectomy of the upper limb in 31 cadaveric limbs using standard and Coude tipped embolectomy catheters. Using a standard embolectomy catheter, the larger of the two upper limb arteries was cannulated in only 42% of our series. However, using a 30 degree Coude tipped catheter, both radial and ulnar arteries could be cannulated in 87% of limbs, ensuring a more complete embolectomy without the need formally to expose the brachial artery bifurcation.

Axillary/Subclavian Vein Thrombosis: A Clinical and Radiological Evaluation of Conservative Management

Over a 10-year period 23 patients had a clinical diagnosis of axillary/subclavian vein thrombosis; excluded from the study are those thromboses secondary to carcinomatosis, local surgery or radiotherapy. At a median follow-up of 16 months (range 3–120), six patients had died and five patients had moved away. Twelve patients were reviewed (nine male and three female) with a median age of 30 years (range 18–62). All had been managed conservatively with arm elevation, heparinization and warfarin therapy. Five patients (42%) were clinically symptomatic, necessitating a change in employment in three patients (25%). Objective signs of chronic venous insufficiency were demonstrable in the same five patients (42%). Repeat venography was obtained in 11 patients, seven of whom were asymptomatic. Evidence of recanalization was seen in nine patients (82%); however, there was no correlation between clinical symptoms and radiographic findings. This disparity highlights the importance of clinical examination over persistent venographic changes in the evaluation of new treatment methods attempting to reduce the morbidity of this condition.