George J. Collins

The effect of acute popliteal venous interruption.

Popliteal vascular trauma continues to be associated with a relatively high morbidity rate when compared to other major vascular injuries in extremities. There is continuing controversy regarding the management of popliteal venous injuries. The advocates of ligation of injured veins have postulated that there is an increased incidence in thrombophlebitis and pulmonary embolism associated with attempted venous repair. There is a paucity of valid statistics supporting either side of this controversy. Clinical experience documented in the Vietman Vascular Registry and experimental work at Walter Reed Army Institute of Research have supported our more aggressive approach for venous repair. This study evaluates the management of 110 injured popliteal veins without associated popliteal arterial trauma. Nearly an equal number were ligated and repaired. Thrombophlebitis and pulmonary embolism were not significant complications in this series. The only pulmonary embolus occurred after ligation of an injured popliteal vein. However, there was a significant increase in edema of the involved extremity following ligation, 50.9% compared to 13.2% after repair

The effects of operative stress on the coagulation profile

There is a tendency toward hypercoagulability in the postoperative period. This is manifested by changes in a number of coagulation parameters, and if not offset by some protective mechanism, thrombosis may occur. This protection appears to be mediated more through the fibrinolytic mechanism than through the action of antithrombin 3 (AT-3) because AT-3 activity diminishes in the early postoperative period. The introduction of variables such as invasion of the vascular system, intraoperative heparin administration, administration of whole blood, and insertion of a Dacron prosthesis does not appreciably affect the response of the coagulation profile to operative stress.

Wound hematomas after carotid endarterectomy

Fifteen of 596 (2.5 percent) carotid endarterectomies performed at Brooke Army Medical Center were complicated by significant wound hematomas requiring reoperation and hematoma evacuation. The wound hematomas resulted from capillary oozing in 80 percent of the cases and arteriotomy bleeders in 20 percent of the cases. Antiplatelet therapy and postoperative hypertension appear to be significant factors predisposing to the development of wound hematomas. In eight cases, local anesthesia was utilized for the hematoma evacuation, and there were no complications. When general anesthesia was utilized for hematoma evacuation, there was considerable difficulty with airway management in six of seven patients. Complications developed in four of these patients. One patient had respiratory insufficiency secondary to laryngeal edema. Two of the patients sustained myocardial infarctions, one of whom died, and a dense neurologic deficit developed in the fourth patient who died as a result of this complication. Meticulous surgical technique in obtaining hemostasis, control of postoperative hypertension, and wound drainage when indicated will help reduce the incidence of postoperative wound hematoma. When a significant postoperative wound hematoma does complicate carotid endarterectomy, the hematoma should be promptly evacuated utilizing local anesthesia.

Popliteal artery entrapment syndrome: Clinical, noninvasive and angiographic diagnosis☆

The popliteal artery entrapment syndrome is increasingly recognized as a cause of arterial insufficiency in the leg. Diagnosis is based on a clinical history of claudication, which may be atypical, physical examination, noninvasive exercise testing and angiography. Patients with normal ankle pulses and resting ankle/brachial pressure indexes may require extensive exercise testing to document arterial insufficiency. Angiographic demonstration of medial deviation of the popliteal artery is diagnostic of the popliteal artery entrapment syndrome. Arteries that appear normal on routine angiography require biplane angiography with various provocative maneuvers to demonstrate induced arterial stenosis. Using this approach, three additional cases of popliteal artery entrapment syndrome were diagnosed preoperatively and successfully treated with surgery.

Vascular trauma secondary to diagnostic and therapeutic procedures: laparoscopy.

Diagnostic and therapeutic laparoscopy are safe procedures that only rarely cause significant morbidity. However, major abdominal arterial and venous injury may occur, requiring prompt recognition and laparotomy. Direct compression will control major hemorrhage until resuscitation is complete. Vascular repair utilizing principles of proximal and distal control, good exposure, appropriate anticoagulation, and lateral suture technic should result in restoration of normal blood flow without significant sequelae.

Autogenous venous interposition grafts in repair of major venous injuries.

1) This review of 51 former Vietnam casualties who had lower extremity venous injuries repaired using autogenous interposition venous grafts is the largest series of this type of venous repair to be reported. Nevertheless, additional information is needed, including more extensive phlebographic documentation of the current status of venous reconstructions. 2) The results of these venous repairs performed by essentially a different surgical team in every case are encouraging. Only one patient, or 2.0% of the total, developed thrombophlebitis in the postoperative period and this was transitory in nature. No patients developed pulmonary embolism. There was no edema in the postoperative period in 66.6% of the total. During the longterm followup, only six patients, or 11.8%, had residual edema. This is in marked contrast to a similar number of patients followed in the Registry who had ligation of popliteal veins following trauma with persistent edema in 50.9%. 3) Although this study remains incomplete, the favorable data should stimulate interest in performing additional repair of major lower extremity venous injuries utilizing autogenous venous grafts. Expanded experimental and clinical research is needed to define a readily available conduit of variable sizes which can be utilized successfully in reconstruction of the low-flow venous system.

Stroke associated with carotid endarterectomy

Between 1966 and 1976, eleven strokes occurred in association with 509 carotid endarterectomies performed at Walter Reed Army Medical Center. Contralateral carotid arterial occlusion with unilateral stenosis, bilateral carotid stenoses, or multiple extracranial (with or without intracranial) stenoses were present in all patients in whom stroke developed. Preventable technical factors contributing to or directly causing stroke were identifiable in six of the eleven patients. Better appreciation of the high risks associated with the above arteriographic patterns and elimination of technical mishaps should lead to an improvement in our already respectably low stroke rate of 2.2 per cent.

Intraoperative local anesthetic injection of the carotid sinus nerve: A prospective, randomized study

One hundred patients undergoing carotid endarterectomy under general anesthesia were prospectively randomized to receive either a local anesthetic injection of their carotid sinus nerve with bupivacaine (Marcaine) or no injection. Systolic blood pressure and pulse rate were recorded before injection and at 5 and 30 minutes after injection. The need for intraoperative and postoperative use of systemic vasopressor and vasodilator medications was recorded for each group as was the incidence of arrhythmias, neurologic complications, and myocardial infarctions. Intraoperative local anesthetic injection of the carotid sinus nerve did not significantly influence the intraoperative pulse rate or incidence of hypotension. It did, however, significantly increase the incidence of intraoperative hypertension and the need for systemic vasodilator medications intraoperatively. The incidence of postoperative hypotension (6 percent of patients), hypertension (34 percent), arrhythmias (6 percent), cerebrovascular accidents (1 percent), transient ischemic attacks (3.1 percent), and myocardial infarctions (2 percent) were not significantly influenced by intraoperative local anesthetic injection of the carotid sinus nerve. Intraoperative and postoperative hypotension did not cause morbidity in this series, however, local anesthetic injection was associated with a significant incidence of perioperative hypertension. Routine prophylactic local anesthetic injection of the carotid sinus nerve cannot be recommended in view of its detrimental effects in relation to the development of hypertension.

Pitfalls in peripheral vascular surgery: Disseminated intravascular coagulation

Disseminated intravascular coagulation is infrequently encountered in the practice of peripheral vascular surgery. Nonetheless, it has devastating and often fatal effects. In our series of eight cases, the mortality rate was 62.5 per cent. A better understanding of the basic disease process as prompted by this review, earlier diagnosis, and rational treatment should lead to higher survival rates and lowered morbidity.

Ocular pneumoplethysmography: detection of carotid occlusive disease.

To determine the accuracy of ocular pneumoplethysmography (OPG-Gee) in detecting carotid arterial occlusive disease, 350 patients were tested by OPG-Gee. Sixty-three patients underwent angiography and the findings were correlated with the results of OPG-Gee tracings. Testing without carotid compression averaged three minutes and was easily performed by a physician or technician. There were no significant complications. Hypertension did not affect evaluation. There were two false-negative tests and no false-positive tests. Without carotid compression the overall accuracy for testing for significant arterial stenosis was 97%. When a carotid compression test was added, the two missed lesions were detected.