Paul T. McDonald

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.

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.

Venous trauma: Successful venous reconstruction remains an interesting challenge☆☆☆

Ligation of some major veins can produce deleterious effects. Based on clinical and experimental research, there is a recent increased interest in repairing injured veins. Despite remaining limitations, successful venous repair has been possible without complications of thrombophlebitis or pulmonary embolism.

Nondialysis uses for vascular access procedures.

Chemotherapeutic agents, blood products and hyperalimentation solutions have been administered and recurrent diabetic ketoacidosis has been treated via vascular access procedures in 13 patients during the period from 1972 through 1977. Bovine heterograft, saphenous vein graft and the direct arteriovenous fistulae have been successfully utilized in the construction of arteriovenous fistulae in patients requiring vascular access for nonhemodialysis purposes. Operative techniques and therapeutic usefulness are discussed.

Phleborheographic diagnosis of venous obstruction.

Between February 1977 and May 1978, phleborheograms were done on 328 extremities. Interpretable tracings were obtained in 322 (98.2%). Results were positive for 102 extremities, negative for 220 extremities, and equivocal or uninterpretable for six extremities. Phlebograms as well as phleborheograms were done in 64 extremities. Phlebograms were positive in 41 and negative in 23. The overall agreement between the interpretations of the phlebograms and phleborheograms was 95.3%. The phleborheogram was positive in each case in which the phlebogram was positive. In three cases with negative phlebograms the phleborheogram was positive. Thus, the sensitivity was 100%, and the specificity was 87%. Phelborheography is a useful ajunct to the diagnosis of venous obstruction. It has a high degree of sensitivity (100% in our experience). Clinical correlation is necessary to determine the most likely cause of venous obstruction in individual cases.

Fallibility of postoperative doppler ankle pressures in determining the adequacy of proximal arterial revascularization

Twenty-three consecutive patients with limb-threatening ischemia underwent proximal arterial revascularization. In all patients Doppler ankle pressure was measured hourly in the postoperative period. In 16 limbs with patent superficial femoral arteries, the pressure index increased from 0.55 +/- 0.06 to 0.78 +/- 0.06 within the 1st hour postoperatively. Twenty limbs with occluded superficial femoral arteries, did not demonstrate a significant increase until 3 hours postoperatively (from 0.41 +/- 0.06 to 0.62 +/- 0.05). Immediate improvement in the Doppler pressure index is to be expected in patients with isolated aortoiliac disease who undergo successful arterial reconstruction. Failure to demonstrate such improvement is diagnostic of an intraoperative accident. Lack of immediate improvement in patients with combined aortoiliac and femoropopliteal disease should not be construed as evidence of intraoperative failure. With 3 to 4 hours, however, the ankle/arm pressure ratio should exceed the preoperative value. The failure to do so within that interval is strongly suggestive of inadequate revascularization, and in most cases immediate operative revision or the later addition of a distal bypass procedure will be necessary.