Henry Haimovici

Progress in limb salvage by reconstructive arterial surgery combined with new or improved adjunctive procedures.

In the past nine years, 1196 patients whose lower extremity was threatened because of infrainguinal arteriosclerosis have been treated at Montefiore Hospital. In the last six years, limb salvage was attempted in 679 or 90% of 755 patients. Femoro-popliteal (318), small vessel (204) and axillopopliteal (29) bypasses were used along with transluminal angioplasty (128) and aggressive local operations to obtain a healed foot. Immediate (one month) limb salvage was achieved in 583 or 86% of the 679 patients in whom revascularization was possible. The 30-day mortality rate was 3%. The cumulative life table (LT) survival rate of all the patients undergoing reconstructive arterial operations was 48% at five years. The cumulative LT limb salvage rate after all reconstructive arterial operations was 66% at five years. The cumulative LT patency rate of femoropopliteal bypasses was not influenced by angiographic outflow characteristics of the popliteal artery but was increased 15% by appropriate reoperations to 67% at five years. Cumulative LT patency and limb salvage rates of small vessel and axillopopliteal bypasses were more than 50% at two years. Of patients undergoing arterial reconstruction, 88% of those who died within five years did so without losing their limbs. Of all the patients in whom limb salvage was attempted, 68% lived more than one year with a viable, useable extremity, and 54% lived over two years with an intact limb. We believe this aggressive approach to limb salvage is justified, and can be undertaken with a low cost in mortality, knee loss and morbidity

Expanded Polytetrafluoroethylene Grafts in Reconstructive Arterial Surgery: Preliminary Report of the First 110 Consecutive Cases for Limb Salvage

One hundred ten arterial reconstructions, including several new and extended bypasses, were performed with polytetrafluoroethylene (PTFE) grafts and were observed for three to 16 months. Patency rates were 100% with 15 bypasses to the femoral artery, 95% with 66 bypasses to the popliteal artery, and 76% with 29 bypasses to the arteries of the leg and foot. These encouraging preliminary results justify continued use and evaluation of PTFE as an arterial prosthesis.

Oxidative Capacity of Atherosclerotic Tissue of Rabbit and Dog, With Special Reference to Succinic Dehydrogenase and Cytochrome Oxidase

The oxidative capacity of the succinic oxidase and cytochrome oxidase systems, as measured by the oxidative response to succinate and p-phenylenediamine was studied in slices of aortas from rabbits and dogs subjected to an atherogenic regimen, and in the liver as reference tissue. In both animals, at an early stage in the atherosclerotic process, the oxidative capacity of both systems was increased in the atherosclerotic intima-media layer, separated at the cleavage plane, while at a later stage it was decreased. The intima-media of the uninvolved portions of the aorta showed a decrease in the oxidative capacity of the cytochrome oxidase system, whereas that of the succinic oxidase system remained unchanged. The liver, although the site of massive deposition of lipids, in the rabbit particularly, showed no enzymatic changes at any time during the administration of the atherogenic regimen. These findings indicate that metabolic alterations of the arterial wall are associated with the development of atherosclerosis.

PATTERNS OF ARTERIOSCLEROTIC LESIONS OF THE LOWER EXTREMITY

The prevailing methods designed to evaluate atherosclerotic lesions of the lower extremity are generally limited in scope since they are usually confined to the study of the femoral-popliteal segment. Such an investigative approach has often yielded inadequate information. A comprehensive assessment of the arterial lesions of the lower extremity, as that of any other well-defined anatomic entity, should include the entire arterial tree, from its origin to its final ramifications. In accord with this concept, the arterial topography of the lower extremity is defined in this investigation as that extending from the origin of the common iliac and the adjacent aortic bifurcation down to the distribution of the pedal arterial tree. Consequently the cases in this study were selected on the basis of these anatomical criteria, so as to obtain complete information not only of the conventional femoral-popliteal segment but also of the entire proximal and distal arterial tree.

Angiographic Evaluation of Arteriovenous Shunting in Peripheral Vascular Diseases

Although arteriovenous anastomoses (AVA) were first described over a century ago (4, 11), their physiologic significance and in particular, their role in vascular diseases still remain ill-defined. Situated proximal to the capillary network, the AVA usually remain completely closed, but in the presence of increased capillary resistance they open up, dilate, and shunt the arterial blood into the venous system (Fig. 1). Usually the shortcircuiting function of the anastomoses is only temporary and lasts as long as the persisting impediment in the capillary bed. Under these circumstances, their action is that of a safety valve. Their clinical role in vascular diseases, although suspected for some time, was not demonstrated until the early part of 1950, and then mostly by a few European investigators (1, 6, 7, 9, 10). Serial arteriography was primarily instrumental in renewing interest in the role of AVA in clinical disorders. Under normal conditions their demonstration directly by arteriography is practically...

METABOLISM OF ARTERIAL TISSUE WITH SPECIAL REFERENCE TO ESTERASE AND LIPASE.

Summary Esterase was demonstrated in normal aortic tissue of dog, rabbit and man. Its activity was determined in various layers of the 3 aortic segments (arch, descending thoracic, abdominal) as well as in liver and serum. Absence of lipase, except for dog serum, was constantly demonstrated. Of the 3 aortic layers studied (innermost intimamedia, media, adventitia), the adventitia displayed the lowest activity, about l/6th that of the other two. Intima-media showed no difference in activity between the 3 aortic segments in dog, or between descending thoracic and abdominal in rabbit or man, whereas a higher activity was noted in rabbits arch. A species difference seems to exist, aortic intima-media showing the lowest values in man, and highest in rabbits arch. A species difference was also noted with regard to liver and serum, the former showing the highest activity in rabbit and lowest in dog, whereas serum showed similar activity in dog and man, and much greater in rabbit.

Arterial Thrombosis Complicating the Thoracic Outlet Syndrome: Arteriographic Considerations

Thrombotic occlusion of the subclavian or axillary arteries, associated with the various thoracic-outlet-compression syndromes, is rare. The early recognition and correction of this arterial complication is most important because of the high incidence of severe secondary ischemic changes in the involved extremity. Precise arteriographic information as to the location and extent of these arterial lesions must be obtained prior to undertaking proper surgical management. Perusal of the literature discloses only a few reports dealing with this aspect of the subject (1–5). We have encountered 4 cases of subclavian-axillary artery thrombosis, 3 of which were associated with cervical rib and 1 with the scalenus anticus and hyper-abduction syndrome. One case has been previously reported (5) and will therefore not be discussed in this communication. Case Reports Case I: W. H., a 38-year-old white male, was admitted to Montefiore Hospital, New York, N. Y., with a four-month history of coldness, numbness, and increa...

EXPERIMENTAL CEREBRAL ATHEROSCLEROSIS IN DOGS

The aortic lesions in experimental canine atherosclerosis have been the subject of reports by Steiner and Kendal1,l Bevans and associates,2 Haimovici and and others, but as far as we are aware no detailed studies have been recorded on the cerebrovascular pathology of dogs. This paper reports on the findings in the intracranial arterial system and the associated cerebral lesions of dogs in which experimental atherosclerosis was induced.

Metabolism of Atherosclerotic Tissue of Rabbit and Dog, with Special Reference to Esterase and Lipase

Esterase and lipase were studied in the aorta, liver, and serum of dogs and rabbits on an atherogenic diet. With the exception of dog serum, lipase was not present in any of the tissues studied. At a relatively early stage the atherosclerotic intima-media layer, separated at the cleavage plane, showed increased esterase activity in both animals. At later stages, a reverse trend was noted in the rabbit, whereas in the dog, the esterase activity remained markedly increased. No pre-atherosclerotic enzymatic changes were noted. The liver of both species showed increased esterase activity first and reversal to normal values later. In contrast, rabbit serum displayed no change for several months and decreased activity subsequently whereas in the dog, decreased esterase activity was noted throughout the administration of the atherogenic diet. Lipase activity in dog serum, which was unaffected for several months, decreased later. Our results expand previous findings with other arterial enzymes and indicate further that metabolic alterations of the arterial wall are associated with the development of atherosclerosis.

Automatic Long-Segment Serial Angiography: A New Unit

Although existing equipment has proved satisfactory for several types of serial angiography covering relatively small areas (cerebral, cardiac, splenic, and aortic), it is increasingly necessary to study longer segments of the vascular system, particularly in the extremities and aorta. The importance of serial roentgenographic examination is now fully accepted. Serial automatic changers covering a small area are available but may require several injections of an opaque medium for study of the entire vascular system of an extremity, with an increased risk to the patient. In some medical centers a variety of manual units have been developed which permit several roentgen exposures of areas up to 14 × 36 inches (1, 2). These long-segment serialographs may provide a satisfactory angiogram with a single injection of contrast material. With the use of manual units, however, there are certain shortcomings: a limited number of exposures, radiation of the physician and technician, and the unreliability inherent in ...