James M. Malone

Prevention of amputation by diabetic education

This prospective randomized study evaluated the influence of a simple education program on the incidence of lower extremity amputation in diabetic patients. Two hundred three patients were randomized into two groups: Group 1, education (103 patients, 203 limbs) and Group 2, no education (100 patients, 193 limbs). There were no significant differences in medical management or clinical risk factors between the two groups. The amputation rate was three times higher in Group 2 (21 of 177 limbs versus 7 of 177 limbs; p less than or equal to 0.025), the ulceration rate was three times higher in Group 2 (26 of 177 limbs versus 8 of 177 limbs; p less than or equal to 0.005), and there was no difference in the overall incidence of infection (2 of 177 limbs). Overall success in Group 1 was highly significantly different from Group 2 (160 of 177 limbs versus 128 of 177 limbs; p less than or equal to 0.0005). This study demonstrated that a simple education program significantly reduced the incidence of ulcer or foot and limb amputation in diabetic patients.

Asymptomatic carotid stenosis: Immediate and long-term results after prophylactic endarterectomy

1. A review of the immediate and long-term results of prophylactic carotid endarterectomy for asymptomatic lesions of 78 carotid arteries in 72 patients between 1961 and 1976 is presented. 2. The inhospital operative mortality was zero. Two patients experienced postoperative transient neurologic deficit with complete recovery (2.6 per cent). There were no postoperative strokes. 3. Late follow-up data demonstrated that in only one patient did a stroke subsequently develop appropriate to the operative side, and it occurred 4 years after operation. Life table analysis for neurologic events carried out for up to 15 years indicated a 96 per cent stroke-free status of the surviving patients. 4. A 42 month survival rate of 83 per cent in patients treated by prophylactic carotid endarterectomy represented a statistically significant improvement over the 67 per cent survival of a comparable group of patients reported on in the literature. 5. Prophylactic carotid endarterectomy in the experience of vascular surgeons who can offer a low operative morbidity and mortality appears to be reasonable therapy in preventing stroke and prolonging survival until a randomized controlled study comparing surgery with the natural history of untreated patients shows evidence to the contrary.

Extrathoracic repair of branch occlusions of the aortic arch

Thirty extrathoracic operations in twenty-six patients with occlusive disease involving the primary branches of the aortic arch were reviewed. Spanning a fourteen year experience, these operations included carotid-subclavian artery bypass, retrograde common carotid artery thrombectomy, carotid-carotid artery bypass, and femoral-axillary artery bypass. Dacron bypass grafts were used primarily for reconstruction, but saphenous vein bypass and endarterectomy were also employed. Indications for operation, the presence of concomitant cardiovascular disease, surgical technics, patient survival, and late patency of the reconstructions were reviewed. One patient died postoperatively (3.85 per cent). All Dacron grafts were patent on late follow-up examinations. Low mortality and excellent late functional results make extrathoracic repair the approach of choice in the management of occlusive disease of the branches of the aortic arch.

Major complications of angioaccess surgery

Angioaccess procedures at one institution over a 4-yearperiod were retrospectively reviewed to ascertain the frequency of major limb- or life-threatening complications. A total of 435 angioaccess procedures were performed, including 81 Cimino-Brescia fistulas, 166 polytetrafluoroethylene grafts, and 111 thrombectomy/revisions. There were 77 operations for major complications in 53 patients. In addition, five patients required major vascular repair or emergency thoracotomy for complications of central hemodialysis line placement. A significant portion (18% of this series) of thetotal angioaccess caseload of a vascular surgeon will be utilized in the repair of major complications. The in-hospital (6 patients, or 11%) and longterm (12 patients, or 23%) mortality rates are significant. Although most complications can be repaired without limb loss and with shunt salvage, a small percentage (in our study three patients, or 4%) will have debilitating long-term symptoms.

Detergent-extracted small-diameter vascular prostheses

The exact mechanism that leads to thrombosis of small-diameter vascular prostheses ( 6 cm) is unknown. This report presents preliminary patency and healing data on a sequential detergent-extraction technique for the preparation of autogenous small-diameter microvascular grafts. Fifteen carotid interpositional allografts (3 to 4 mm × 4 to 6 cm) were implanted in 15 mixed species adult greyhounds. Ninety days after implantation grafts were perfusion-fixed in situ, harvested, and evaluated by light microscopy and scanning and transmission election microscopy. Two categories of acellular vascular matrix grafts were evaluated: non—cross-linked and cross-linked (1% carbodiimide). By objective morphologic analysis with blind random view, histologic sections were rated from 0 to 4 in five categories believed to be important for graft healing and patency. Overall graft patency was 8% (12 of 15), and there was no significant difference between cross-linked and non-cross-linked grafts. Non—cross-linked grafts were superior to cross-linked grafts in all areas of histologic evaluation except immunogenicity (p < 0.01). Most important, non—cross-linked grafts demonstrated complete endothelial coverage (p < 0.001). There was no significant difference (that is, normal) between control autografts and non—cross-linked grafts; however, there was a significant difference between control autografts and cross-linked grafts in all parameters except immunogenic reaction (p < 0.01). (J. VASC SURG 1984;1:181-91.)

Timing of carotid endarterectomy after acute stroke

An arbitrary delay of at least 6 weeks before performing carotid endarterectomy after acute stroke has been recommended based on anecdotal reports. This prolonged interval may increase the danger of recurrent neurologic deficit before surgery. From September 1978 to September 1988, carotid endarterectomy was performed on 140 patients at variable intervals after stroke. Eleven patients had temporary stroke, which left 129 patients with neurologic symptoms that persisted for 3 weeks or had a cortical infarct on CT scanning. A prospective therapeutic protocol was applied to 82 patients admitted with acute stroke. They were observed until neurologic recovery reached a plateau, based on clinical observation by a neurologist, before performing angiography and carotid endarterectomy (group I). Forty-seven patients were not seen until after recovery from stroke was established (group II). At initial presentation, the severity of neurologic deficit was classified as mild, moderate, or severe in 31%, 58%, and 11%, respectively. Recovery before operation was registered as complete in 11%, mild residual in 66%, moderate residual in 21%, and severe residual in 2%. Group I patients (n = 82, 64%) were operated on within 6 weeks of stroke and group II (n = 47, 36%) were operated on at varying times after 6 weeks. No significant difference was found in the incidence of cerebrovascular events (1.2% vs 4.2%) and deaths (1.3% vs 2.1%) between groups I and II with respect to the timing of carotid endarterectomy, and no significant difference was found between patients operated on at 2, 4, 6, or more than 6 weeks after stroke.(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective comparison of noninvasive techniques for amputation level selection

This study prospectively compared the following tests for their accuracy in amputation level selection: transcutaneous oxygen, transcutaneous carbon dioxide, transcutaneous oxygen-to-transcutaneous carbon dioxide, foot-to-chest transcutaneous oxygen, intradermal xenon-133, ankle-brachial index, and absolute popliteal artery Doppler systolic pressure. All metabolic parameters had a high degree of statistical accuracy in predicting amputation healing whereas none of the other tests had statistical reliability. Amputation site healing was not affected by the presence of diabetes mellitus nor were the test results for any of the metabolic parameters.

The relevance of arterial wall microbiology to the treatment of prosthetic graft infections: Graft infection vs. arterial infection

One potential, but poorly studied source for intraoperative contamination of vascular grafts is the native artery to which the prosthetic graft is attached. The purpose of this study was to analyze the relationship between arterial wall microbiology and graft infection. Between July 1, 1981, and March 31, 1982, arterial specimens were cultured from 88 (30%) of 298 patients undergoing clean, elective arterial reconstructive procedures. Control cultures were obtained from adjacent adipose or lymph node tissue. Positive cultures were obtained from 38 of 88 (43%) of the arterial walls cultured but from none of the control cultures (0 of 20) (p less than 0.001). The most common organism cultured was Staphylococcus epidermidis (27 of 38; 71%). Our overall graft infection rate since January 1, 1981, is 0.9% (3 of 335). All three graft infections occurred in patients with positive arterial cultures. Arterial and graft cultures were also obtained from 20 patients treated for 22 graft infections over the past 13 years. Organisms recovered included staphylococcal species (36%), enteric organisms (46%), and mixtures of the two (18%). These patients with culture-positive graft infections were divided retrospectively into two groups: those with positive and those with negative arterial cultures. Positive arterial cultures were associated with suture line disruption in 8 of 14 cases (57%), but there were no arterial disruptions in patients with negative cultures (0 of 8) (p less than 0.01). These data document a significant correlation between positive arterial wall cultures and subsequent prosthetic infection and also suggest that infection involving the arterial wall is a major determinant of the morbidity and mortality associated with the treatment of prosthetic graft sepsis.

Therapeutic and Economic Impact of a Modern Amputation Program

The experience with 142 below-knee amputations for vascular occlusive disease and/or diabetes mellitus in 133 patients has been reviewed. The program utilized Xenon133 skin bloodflow measurement for the selection of amputation level, emphasized the use of the long posterior skin flap as an important part of surgical technique, and employed immediate postoperative prosthesis with accelerated rehabilitation for postoperative management. The results of this program yielded a 0% postoperative mortality, 89% amputation healing, and 100% prosthesis rehabilitation of all unilateral below-knce amputees, and 93% rehabilitation of all bilateral below-knee amputees. The average time interval between amputation and fitting of a permanent prosthesis was 32 days. The use of Xenon133 clearance as a measurement of capillary skin bloodflow for purposes of amputation level selection continues to be valid. AH amputations with flows in excess of 2.6 ml/100 g tissue/min healed primarily, including the last 58 consecutive amputations. The total amputation of the 172 hospital V.A. system was surveyed and a cost analysis, based upon duration of postamputation hospitalization, comparing immediate postoperative prosthesis with conventional techniques, was performed. The savings to the system, taking into account start-up and maintenance costs for a program which employs immediate postoperative prosthesis, was projected to be

Fibrinolytic treatment of residual thrombus after catheter embolectomy for severe lower limb ischemia

80,000,000 over five years. We conclude that a modern amputation program employing Xenon133 clearance for amputation level selection and immediate postoperative prosthesis with accelerated rehabilitation is well justified based upon reduced morbidity, negligablc mortality, and optimum patient prosthetic rehabilitation at a marked reduction in overall cost.