Acute ischemia of the arms

The article analyzes results of the treatment of 162 patients with acute ischemia of upper extremities. Acute ischemia of upper extremities was shown to be an absolute indication for operation aimed at the reestablishment of adequate bloodflow. The character of surgery is predetermined mainly by genesis of acute ischemia. Postoperative lethality was 8.8%.     

Criteria of rehabilitation of patients and invalids operated on for arteriosclerosis obliterans of the blood vessels of the legs

A complex clinico-functional examination of 103 patients and invalids operated for obliterating atherosclerosis of the lower extremity vessels was carried out. Clinico-functional criteria for the assessment of the degree of chronic arterial insufficiency are proposed. The leading criterion of rehabilitation is found to be the degree of compensation of circulation. Complex application of the above methods in combination with clinical findings helps to make an objective assessment of the peripheral circulation state and of efficiency of the operation in remote periods of time.     

Prolonged dopmin infusion in severe respiratory insufficiency in newborn infants

An effective use of continuous infusion of Dopmin in dose of 2-3 mkg/(kg/min) is described. Dopmin was used in 13 newborns with severe respiratory insufficiency due to postasphyxial syndrome, disease of hyaline membranes and congenital diaphragmal hernia. Continuous infusion of microdoses of Dopmin with artificial ventilation of lungs against the background of a decreased respiratory insufficiency according to clinico-laboratory evidence resulted in decreased value of bloodflow shunt from right to left and oxygen concentration in the inhaled mixture to 45%.     

Disorders of the "lipid peroxidation-antioxidant" system and ways of their correction after transplantation of vascularized tissue complexes

An experimental investigation in 40 rabbits and 13 dogs has shown that arrest of blood flow in tissues is accompanied by activation of lipid peroxidation processes with reduced activity of the antioxidant system. Tissue anoxia during 4h sharply activates lipid peroxidation processes which is considerably aggravated after early performance of oxygenobarotherapy sessions (1h after revascularization). Relatively late sessions of oxygenobarotherapy (10h after the reestablishment of bloodflow) are not accompanied by activation of lipid peroxidation and decrease of the level of antioxidants of lipid nature, alpha-tocopherol acetate has a marked antioxidation effect and enhances tissue survival after anoxia.     

Early prognostic factors of the surgery of aneurysms of the abdominal aorta with renal artery clamping]

The aneurysms of the abdominal aorta requiring suprarenal clamping are rare. Suprarenal clamping was required for only 43 of 544 aneurysms operated electively from 1981 to 1989. Twenty-five patients had a juxtarenal aneurysm, without any normal aortic segment under the renal arteries, and suprarenal clamping was therefore necessary while the upper anastomosis was being established (group I). Eighteen patients had an aneurysm enclosing the root of at least one renal artery (group II). Several prognostic factors have been assessed: patient's age, presence of preoperative renal insufficiency, of arterial hypertension or of coronary insufficiency, and revascularization method. Five patients died. Four of them belonged to group II and were over 75 years old. All presented with a preoperative renal insufficiency. Two of these deaths were caused by mesenteric infarction. Four cases of regressive postoperative renal insufficiency were observed in patients for whom renal clamping had lasted longer than 45 minutes. This study allowed outlining three prognostic factors: the patient's age, preoperative renal insufficiency, a period of renal ischemia exceeding 40 minutes. On the other hand, the severity of hypertension had no predictive value. Coronary insufficiency requires a strict hemodynamic surveillance, but is not a contraindication for revascularization.     

Acute insufficiency of the gastrointestinal tract in patients with severe gunshot injury

Acute insufficiency of the gastrointestinal tract (GIT) in patients with severe gunshot injuries is an important link of pathogenesis of the polyorganic insufficiency syndrome. The character of the wound, the numerical score objective assessment of the injury severity and severity of the patient's state are considered to be criteria of early diagnosis of a risk of the development of acute insufficiency of GIT. The specific feature of "general" intensive therapy of acute insufficiency of GIT in severe gunshot traumas is the necessary application of regional anesthesia, sympatholytics, anticholinesterase agents and H2-blockers. Intensive "enteral" therapy of acute insufficiency of GIT in severe gunshot wounds includes the measures resulting in improvement of microcirculation, tissue respiration in organs of GIT, decompression of the stomach, local defense of mucosa, detoxication and early enteral balanced nutrition. The described method of treatment of wounded to the stomach used at specialized medical institutions resulted in 6.2 less lethality among this category of patients.     

Relation of C-reactive protein and other cardiovascular risk factors to penile vascular disease in men with erectile dysfunction

Erectile dysfunction (ED) may be an early sign or symptom of cardiovascular disease (CVD). We examined the relation of traditional and emerging risk factors for CVD to the severity of penile vascular disease in men with ED and without clinical coronary artery disease (CAD). In total, 137 men with ED were evaluated for penile vascular disease severity by penile Doppler ultrasound. These men were divided into the following groups based on ultrasound results: normal, cavernous venous occlusive disease, mild arterial insufficiency, and severe arterial insufficiency. Traditional (fasting lipid panel, fasting glucose, age, BMI, smoking, Framingham coronary artery disease risk score) and emerging (C-reactive protein, Lp(a), homocysteine) risk factors for CVD were correlated to severity of penile vascular disease in men with ED and without clinical CAD. Using univariate analysis, penile Doppler groups showed significant positive correlation to CRP (r=0.21; < or = 0.05) and age (r=0.30; < or = 0.01). For CRP, this correlation remained significant even when adjusted for age (< or = 0.05). Men displaying evidence of penile arterial disease (mild and severe arterial insufficiency) were characterized by elevated CRP levels (0.17 mg/dl) compared to men with no evidence of arterial abnormalities in the penis (0.04 mg/dl). CRP levels correlate significantly with increasing severity of penile vascular disease as measured by penile Doppler.     

Adventitial Cystic Disease of the Axillary Artery

Adventitial cystic disease (ACD) is an extremely rare cause of arterial and venous insufficiency, with only 317 reported cases in the world literature. These lesions have been previously described in the popliteal fossa, external iliac artery, and distal brachial, radial, and ulnar arteries as well as in the proximal saphenous vein at the ankle. We describe here the first reported case of this disease in a proximal vessel, the axillary artery. A 33-year-old man was evaluated for upper extremity arterial insufficiency and was diagnosed with ACD on the basis of physical examination and radiographic findings, which was confirmed by pathological assessment. The patient was treated by excision of the lesion and interposition vein bypass. As this represents the first case of ACD in the proximal vasculature, it demonstrates that these lesions can occur in axial blood vessels.     

The peripheral blood pressure in legs with venous ulcers.

Venous ulcers require effective compression treatment which is, however, contra-indicated in cases of arterial insufficiency. In elderly patients with typical venous ulcers the question arises whether they may have concomitant arterial insufficiency. In early studies is was proved that arterial insufficiency in the lower limbs may be diagnosed as a low systolic blood pressure in the great toe as compared with the systolic arm blood pressure. In the present investigation the systolic blood pressure in the great toe was measured in 48 patients with verified venous ulcers. The toe blood pressure and the pressure difference from arm to toe were studied and compared with the corresponding values in normal subjects. 35 patients had no evidence of arterial insufficiency, but in 13 cases signs of concomitant arterial insufficiency was found. The method of measuring the systolic blood pressure in the toes seems to be a simple and reliable method for estimating the degree of arterial insufficiency even in patients with chronic venous disease.     

Leg ulcer etiology--a cross sectional population study

Three hundred eighty-two patients with active leg ulcers were clinically examined after random selection out of a population of 827 patients identified within a previous cross-sectional population survey. Bidirectional Doppler ultrasonography was used for objective assessment of arterial and venous circulation. The purpose was to register causative factors and the etiologic spectrum. Venous insufficiency was present in 332 (72%) of 463 legs with active ulceration; deep insufficiency occurred in 176 (38%), and purely superficial insufficiency was present in 156 (34%). Ankle/brachial index was 0.9 or less in 185 (40%) of ulcerated legs. Venous insufficiency was the dominating causative factor in 250 legs (54%), of which 60% was the result of deep venous insufficiency. Arterial insufficiency was judged to be the possible dominating factor in 12%, and 6% showed clearly ischemic ulcers. Mixed ulcers with combined arterial and venous insufficiency were found to be common as were patients with diabetes and arterial impairment. In 10% of the legs a multifactorial origin was present, and in 10% no venous or arterial impairment was detectable. Thus after classification of causes 40% of all ulcerated legs showed potentially surgically curable circulatory disturbances. It is necessary to objectively assess all patients with chronic leg ulcers to be able to detect patients with potentially surgically curable disease.     

Doppler blood flow analysis of erectile function: who, when, and how

The underlying processes in vasculogenic erectile dysfunction (ED) are arterial insufficiency, venoocclusive disease, or combinations of both. Doppler blood flow analysis is a diagnostic modality useful in elucidating the cause of ED and the magnitude of its severity. This article describes the procedural techniques, typical findings, and relevant pathophysiology for in-office Doppler studies. Specific conditions include arterial insufficiency, venous occlusive disease, Peyronie's disease, and priapism.     

Blood flow "stealing" phenomenon in the foot as one of the causes of ischemia of the toes

An examination of 750 patients with chronic ischemia of lower extremities has revealed 12 patients whose foot arteries pulsation could be determined by pulpation. However, by means of angiography of the ischemic lower extremity, ultrasound flowmetry of the foot arterial arch with the use of compression tests these patients were found to have the syndrome of "robbing" the foot bloodflow.     

Differential response of the systemic and pulmonary circulation related to disease severity of cirrhosis

BACKGROUND: In cirrhotic patients, the degree of hepatic insufficiency has been related to a physiological landmark: arterial vasodilatation. We sought to assess how the severity of disease, which was stratified according to the Child-Pugh criteria, influences the pulmonary and systemic circulation among patients undergoing liver transplantation. METHODS: We studied 86 cirrhotic patients in three groups: grade A (n = 10), grade B (n = 54), and grade C (n = 22). The outurnes were classified based upon a complete hemodynamic profile obtained using a pulmonary artery catheter (RVEF, Baxter-Edwards, Calif, USA) after induction of anesthesia. The variables were mean arterial and pulmonary artery pressures and cardiac index (CI). Using standard formulae, afterload was calculated as elastance of systemic (Es) and pulmonary (Ep) arterial beds, expressed by the ratio of end-systolic pressure to stroke volume. The relation between pulmonary and systemic circulation was also evaluated by the ratio (Ep/Es). RESULTS: Es was significantly lower in each class than in previous one. Also, Ep was smaller in class B than in class C patients. In addition, CI was significantly higher with disease severity. CONCLUSION: We observed that the hyperdynamic circulation in cirrhosis is directly related to severity of disease. Nevertheless Ep/Es was progressively higher among each group; these data suggest that the hyperdynamic circulation is mainly due to circulatory alterations in the splanchnic area. We conclude that pulmonary vasodilatation is directly related to the severity of cirrhosis, although its evolution is independent of other vascular areas.     

Comparison of the immediate effects of etomidate, propanidid and thiopentone on haemodynamics, coronary bloodflow and myocardial oxygen consumption.

Since cardiovascular depression at induction is among the most common complications of anesthesia this comparative study was undertaken. Unpremedicated dogs (n = 16) were induced with 3 mg/kg piritramide i.v. and normoventilated (N2O/O2 = 2/1). In 8 animals 0.8 and 1.6 mg/kg Etomidate and 5.0 and 10.0 mg/kg thiopentone and in 8 further dogs 5.0 and 10.0 mg/kg Propanidid were tested. Equipotent doses of Thiopentone and Propanidid caused a marked myocardial depression, which was seen in a decrease in stroke volume and max dp/dt and in an increase of leftventricular end-diastolic pressure and pulmonary arterial pressure. The increased myocardial O2- cosumption mainly due to the rise in heart rate was covered after Thiopentone by an increase of coronary bloodflow (measured with a pitot-catheter) and an increase of arterio-coronaryvenous difference in oxygen.As the latter decreased after Propanidid, it appeared that Propanidid has coronary dilatory properties. The results demonstrated the uneconomic work of the heart under the influence of Thiopentone and Propanidid. In contrast to this the cardiovascular system after Etomidate remained nearly unaffected. The data of this study suggest the use of Etomidate rather than Thiopentone and Propanidid in cases of shock syndrome, heart and/or coronary insufficiency.     

Skin perfusion pressure of the foot is a good substitute for toe pressure in the assessment of limb ischemia

PURPOSE: Noninvasive measurements of limb systolic pressures are used routinely in the assessment of the severity of peripheral arterial disease, including the evaluation for critical limb ischemia. However, ankle pressures cannot be measured reliably in patients with medial calcification, which is especially common among patients with diabetes. Skin lesions on the toes or previous digital amputations may preclude the measurement of toe pressures. Measurements of skin perfusion pressure (SPP) are not subject to such limitations and were shown to be useful in the assessment of the severity of peripheral arterial disease. Because toe pressure is often used in the evaluation of severity of arterial disease and in the assessment for critical ischemia, we undertook to study whether there is a sufficient correlation between toe pressure and foot SPP that would allow the use of SPP measurements when toe pressures cannot be measured. METHODS: Measurements were carried out in 85 limbs of 71 patients referred to the vascular laboratory for evaluation for peripheral arterial disease. Diabetes mellitus was present in 43 patients. Each patient had foot SPP and toe pressure measurements. Toe pressures measured with photoplethysmography were correlated with foot SPP measured with laser Doppler scanning. RESULTS: There was a strong linear correlation between SPP and toe pressure (r = 0.87; P <.01). Also, significant correlation was found in both the patients with diabetes and the patients without diabetes (r = 0.85 and 0.93, respectively; P <.01 in both cases). CONCLUSIONS: We concluded that SPP measured in the foot correlates well with toe pressure and can be substituted for toe pressure measurement in patients in whom toe pressures cannot be measured.     

Cardiac output determination from the arterial pressure wave: clinical testing of a novel algorithm that does not require calibration

OBJECTIVE: The purpose of this study was to evaluate the accuracy and precision of a novel algorithm that evaluates cardiac output by using arterial pressure waveform characteristics. DESIGN: Prospective, observational study comparing the cardiac output values of intermittent thermodilution, continuous thermodilution, and continuous arterial pressure wave assessment. SETTING: The intensive care unit in a tertiary care university hospital. PARTICIPANTS: Fifty postoperative cardiac surgical patients, within the first 12 hours after surgery. Interventions: All patients received a pulmonary artery catheter (PAC) and at least 1 systemic arterial pressure catheter. The data from the arterial catheter were processed by using a new arterial pressure cardiac output (APCO) algorithm. The data from the PAC (continuous and intermittent assessments) were collected for comparison with the APCO. Measurements: Two hundred ninety-five cardiac output measurements using intermittent thermodilution (ICO), continuous thermodilution (CCO), and arterial pressure-based output (APCO) were obtained during various times during the first 12 postoperative hours. The measurements of each method at each time point were compared by using Bland-Altman analysis. RESULTS: The mean cardiac output ranged from 2.77 to 9.60 L/min. APCO, compared with ICO, revealed a bias of 0.55 L/min and precision of 0.98 L/min. APCO, compared with CCO, revealed a bias of 0.06 L/min and precision of 1.06 L/min. The APCO agreement between femoral and radial arterial catheters was close; the bias was -0.15 L/min, and the precision was 0.56 L/min. CONCLUSIONS: This novel arterial pressure cardiac output algorithm provides cardiac output assessments that agree satisfactorily for clinical purposes with intermittent and continuous thermodilution techniques in postoperative cardiac surgical patients. Further study is required for other patient populations and clinical situations.     

Tibial fractures with infrapopliteal arterial injuries

Tibial fractures with associated infrapopliteal arterial injuries have been inadequately documented in the literature. Eighteen patients with these injuries were admitted to Boston City Hospital during a 10-year period. Three patients required below-knee amputation, and two of these had ischemic intervals of greater than 8 h before vascular treatment. Six patients had delayed diagnoses of arterial injuries, but none required amputation. There were 15 open and three closed tibial fractures. Nine fractures were badly comminuted. Eight of the 14 viable limbs had delayed unions, but only one was associated with local vascular insufficiency. Five patients had complaints attributed to vascular insufficiency without clinical findings. Our conclusion is that the limb with an infrapopliteal arterial insult combined with a tibial fracture can survive with patency of only the anterior tibial or posterior tibial artery. Poor clinical results correlate with the severity of bony injury and not with the particular arterial injury. The incidence of below-knee amputation can best be related to delay in vascular treatment.     

HAEMODYNAMIC EFFECTS OF LABETALOL-INDUCED HYPOTENSION IN THE ANAESTHETIZED DOG

Central haemodynamic changes and regional blood flow were studiedusing the microsphere technique, during labetalol-induced hypotensionin dogs anaesthetized with pentobarbitone and fentanyl. Labetalol15 mg kg^–1 decreased mean arterial pressure from an averageof 88 mm Hg to 47 mm Hg. Mean pulmonary arterial pressure wasunchanged. Cardiac output was reduced by decrease in strokevolume, while heart rate remained unchanged. Myocardial bloodflow decreased approximately in parallel with left ventricularwork. Perfusion of the brain and kidneys was unchanged.     

Angiographic evaluation of the results of roentgeno-endovascular occlusion of the hepatic artery

Angiographic examinations of 42 patients after percutaneous embolization of the hepatic artery system were performed for dearterialization of the tumour or reduction of the arterial bloodflow in cirrhosis of the liver complicated by portal hypertension. High effectiveness of metallic spiral emboli was revealed for the creation of stable permanent action on different portions of the hepatic artery. The results obtained show high efficiency of proximal embolization of the hepatic artery in treatment of tumors and cirrhosis of the liver and its advantages over the surgical ligation.     

JPN Guidelines for the management of acute pancreatitis: severity assessment of acute pancreatitis

This article addresses the criteria for severity assessment and the severity scoring system of the Ministry of Health and Welfare of Japan; now the Japanese Ministry of Health, Labour, and Welfare (the JPN score). It also presents data comparing the JPN score with the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Ranson score, which are the major measuring scales used in the United States and Europe. The goal of investigating these scoring systems is the achievement of earlier diagnosis and more appropriate and successful treatment of severe or moderate acute pancreatitis, which has a high mortality rate. This article makes the following recommendations in terms of assessing the severity of acute pancreatitis: (1) Severity assessment is indispensable to the selection of proper initial treatment in the management of acute pancreatitis (Recommendation A). (2) Assessment by a severity scoring system (JPN score, APACHE II score) is important for determining treatment policy and identifying the need for transfer to a specialist unit (Recommendation A). (3) C-reactive protein (CRP) is a useful indicator for assessing severity (Recommendation A). (4) Contrast-enhanced computed tomography (CT) scanning and contrast-enhanced magnetic resonance imaging (MRI) play an important role in severity assessment (Recommendation A). (5) A JPN score of 2 or more (severe acute pancreatitis) has been established as the criterion for hospital transfer (Recommendation A). (6) It is preferable to transfer patients with severe acute pancreatitis to a specialist medical institution where they can receive continuous monitoring and systemic management.