Peter Qvarfordt

Thrombectomy with temporary arteriovenous fistula: The treatment of choice in acute iliofemoral venous thrombosis

The treatment of choice in acute iliofemoral venous thrombosis is still controversial. This prospective randomized study compares the results of conventional anticoagulation of 32 patients with the results obtained in 31 patients undergoing acute thrombectomy combined with a temporary arteriovenous fistula and anticoagulation. Early complications were few in both treatment groups, and significant pulmonary embolism developed in only one conservatively treated patient. At 6-month follow-up in all surviving patients, leg swelling, varicose veins, and venous claudication were more frequent after conservative treatment. Only 7% (2 of 27) of these patients were completely free from postthrombotic symptoms compared with 42% (10 of 24) of the operated patients (p less than 0.005). Contrast phlebography demonstrated an excellent venous outflow through the iliofemoral segment in 35% (9 of 26) of the conservatively treated and in 76% (16 of 21) of the operated patients (p less than 0.025). Open femoropopliteal veins with competent valves were recorded in 26% (7 of 27) in the conservative group and in 52% (12 of 23) in the thrombectomy group (p less than 0.05). Thus thrombectomy combined with arteriovenous fistula decreases early symptoms and preserves venous outflow and valvular function better than conservative treatment. This procedure is therefore recommended for young patients with acute iliofemoral thrombosis to avoid development of incapacitating postthrombotic sequelae.

Intramuscular pressure, muscle blood flow, and skeletal muscle metabolism in chronic anterior tibial compartment syndrome.

One hundred eight patients with lower leg pain of unknown cause underwent intramuscular pressure measurements by the wick technique. Fifteen patients (14%) were found to have a chronic anterior tibial compartment syndrome. In these patients the intramuscular pressure was significantly increased at rest and during and after exercise as compared with normal subjects. The pressure increase after exercise was long-lasting (40 minutes). Biopsies of the anterior tibial muscles showed increased water content, which may explain the elevated pressures. Muscle blood flow during exercise as measured by the xenon-133 clearance technique was decreased, and muscle lactate concentration was increased in the anterior tibial muscles. Fasciotomy relieved pain and normalized intramuscular pressure, muscle blood flow, and skeletal muscle metabolism.

Supraclavicular radical scalenectomy and transaxillary first rib resection for the thoracic outlet syndrome: A combined approach☆☆☆

Transaxillary resection of the first rib alone was performed 97 times to relieve symptoms of irritation of the brachial plexus. Persistent or recurrent symptoms occurred in a fifth of the patients (7 and 13 patients, respectively), and necessitated reoperation using the supraclavicular approach. In all patients, at least one anomaly or acquired deformity was found that could not have been identified or safely removed by the original transaxillary approach alone. Subsequently, 94 combined operations, including supraclavicular radical scalenectomy with neurolysis of the brachial plexus and transaxillary resection of the first rib, were performed for irritation of the brachial plexus. The improved results using the combined procedure has led us to recommend it for the majority of symptomatic patients with irritation of the brachial plexus. The combined approach allows precise assessment of the thoracic outlet anatomy, facilitates first and cervical rib resection, and permits removal of any additional congenital or acquired lesions. It is associated with a low failure rate and results in few postoperative complications. However, the transaxillary approach alone may be suited for the patient with localized lower plexus symptomatology, keeping in mind the risk of recurrent symptoms associated with this technique.

Intramuscular pressure in the lower leg in deep vein thrombosis and phlegmasia cerulae dolens.

The influence of deep vein thrombosis on intramuscular pressure was evaluated in 22 patients by means of the wick technique. Intramuscular pressure was measured in the anterior tibial and the deep posterior compartments in both legs before and during treatment. The intramuscular pressure was significantly (p less than 0.001) higher in the thrombosed leg than in the contralateral leg (0-16 mmHg). The increase in intramuscular pressure was related to the extension of the thrombus. Iliofemoral thrombosis caused a significantly (p less than 0.001) higher pressure (17-28 mmHg) than calf thrombosis (16-23 mmHg). A compartment syndrome was found to be a part of the entity phlegmasia cerulea dolens (rest pressure 47-56 mmHg). In the treatment of phlegmasia cerulea dolens, fasciotomy is suggested additional to other therapeutic procedures.

Computerized tomographic assessment of graft incorporation after aortic reconstruction

Computerized tomographic scanning is being used with increasing frequency for the detection of abdominal aortic prosthetic complications. Although computerized tomography remains a very precise method for direct imaging of the retroperitoneal space, the interpretation of a postoperative computerized tomographic scan is limited by the absence of any information on the normal appearance of the routine uncomplicated aortic graft. To study the normal tissue incorporation of aortic grafts, 29 patients were evaluated with periodic postoperative computerized tomographic scans. Seventeen patients had aortoiliac occlusive disease and 12 had aneurysmal disease. No patients who had reoperation were included and all patients had a normal postoperative course. Computerized tomographic scans were obtained in the early (mean 7 days), intermediate (mean 48 days), and late (mean 102 days) postoperative periods. A variable amount of perigraft hematoma was always present on the initial computerized tomographic scan. Perigraft air was seen in only four patients in the early study. Graft incorporation appeared complete in these patients by 48 days, although minimal hematoma persisted in one patient. This study provides baseline data on the appearance and timing of aortic graft incorporation which should facilitate subsequent computerized tomographic detection of aortic graft complications.

Juxtarenal aortic atherosclerosis. Surgical experience and functional result

Ninety patients underwent combined aortic (90) and renal artery (138 arteries) reconstruction for severe, symptomatic aortic occlusive disease (47 patients), aortic aneurysmal disease (30 patients), and visceral atherosclerosis (13 patients). Transaortic endarterectomy was used for 67% of renal artery reconstructions and 69% of visceral arteries. Aortic reconstruction required prosthetic grafting in 74%. A standard transabdominal approach was used in 72 of 90 patients (80%), and thoracoretroperitoneal exposure was necessary in 18 patients. Perioperative mortality was 9% (8/90) and morbidity 16% (14/90). Ninety per cent of the patients were evaluated at long-term (mean 32 months). Hypertension was cured or improved at discharge in 82% (59/72), and in 96% hypertension improvement was sustained during the follow-up interval. Renal function was improved or preserved in 93% (40/43) at discharge, and this response was sustained in 84% during the follow-up period. Late mortality (8/74,11%) was lower than expected and is attributed to the technique of combined repair, the cure and control of hypertension, the prevention of ongoing renal ishcemia, and the preservation of renal function.

The early platelet uptake and distribution of platelets in small-diameter polytetrafluoroethylene (PTFE) vascular grafts in vivo.

Platelet deposition onto the surface of biomaterial is an important component of the interaction between blood and a prosthetic arterial graft. To understand the thrombotic process in small-diameter by-pass grafts, we used pigs to study the early in vivo uptake of 111In-oxine-labelled platelets in polytetrafluoroethylene (PTFE; GoreTex) grafts. In each experimental animal, 12 PTFE grafts (internal diameter, 3 mm; length, 5 cm) were placed in the femoral artery as interposition grafts. 111In-Labelled autologous platelets were injected. Sequential-scintillation camera images of the graft area were taken over a period of 3.5 h. Platelet deposition in vivo was calculated as an activity ratio for the entire grafts as well as for different segments of the graft. The grafts were harvested, cut into 0.6-cm pieces and weighed, and the 111In activity was measured. The distribution along the graft surface was calculated. Blood flow was measured continuously. The activity ratios rapidly increased, and a maximum was reached 60 min after the re-establisment of blood flow; thereafter the activity ratios slowly decreased. The distribution of platelets along the graft surface was found to be non-uniform where more platelets were deposited towards the distal anastomoses.

Revascularization of the Femoral Artery by Femoro-Femoral Cross-Over By-Pass Utilizing PTFE-Grafts. Hemodynamic Changes During Follow-Up

From 1976 to 1981, 48 consecutive patients underwent femoro-femoral cross-over by-pass utilizing PTFE grafts. Indications were severe ischemia (69%) and claudication (31%). All were high-risk patients. Hemodynamic changes (ankle/brachial pressure index) and graft patency was studied during the first postop year. No operative mortality was noticed. Graft thrombosis occurred in 13 cases during follow-up. Successful thrombectomy was done in 7 cases. Graft patency was 80% after 5 years in claudicants and 81% in severe ischemia. The limb salvage rate was 70% at 6 years follow-up. The walking distance increased sig nificantly during the 1st year. There was a good correlation between angiografi cally determined run-off and the ankle/brachial pressure index. In claudicants distal pressure index increased significantly from 0.38 to 0.60, 3 months postop in recipient leg. The same was true in severe ischemia, from 0,10 to 0.48, 3 months postop. No steel phenomena were observed. This procedure is useful for revascularization of a limb with occlusion of the iliac artery, with high graft patency and limb salvage rates and low morbidity and mortality. Even though ankle/brachial pressure index never is restored to normal a gradual increase is observed up to one year after operation. No adverse effects have been demon strated following the procedure. Patients have to be carefully selected for the procedure by preop angiography and hemodynamic evaluation.