Ist die infrainguinale Rekonstruktion der arteriellen Strombahn mit autologer Vene im Stadium der limitierenden Klaudikation gerechtfertigt?

Infrainguinal arterial reconstruction for intermittent claudication has been discouraged because of fear of bypass graft failure, significant perioperative complications, and limb loss. This may be worse than the natural history of the disease. In our study, we retrospectively evaluated all infrainguinal bypass procedures performed in the past 10 years.From October 1988 to December 1998, we performed 421 infrainguinal arterial reconstructions, 115 (27.2%) for debilitating claudication and 306 (72.8%) for critical ischemia in 410 patients. The average age was 73.2 years (range 20–86 years). There were significantly more diabetics with critical ischemia (183 versus 14, P=0.000). Other risk factors (smoking, hypertension, hyperlipidemia) were evenly distributed in both groups. Follow-up was scheduled in our vascular laboratory.The primary patency rates were 64.8% for intermittent claudication and 54.2% for critical ischemia at 7 years (P value not significant), and the primary assisted patency rates were 86.1% and 79.3%, respectively (P value not significant). There were 2 patients (1.7%) with limb loss in the follow-up period (3 and 5 years after operation, respectively). Both patients were diabetics, who had to be amputated with patent grafts because of progressive forefoot gangrene. The 30-day mortality rate was 0.8% (1 patient died on the second postoperative day due to cardiac failure).In our experience, patients with debilitating claudication have to be managed by a team of angiologists, radiologists, and vascular surgeons. The use of autologous vein, intraoperative angioscopy, and a scheduled follow-up program may be the cornerstones for excellent long-term results. These results justify operation in selected cases.     

Effects of intermittent pneumatic compression of the calf and thigh on arterial calf inflow: a study of normals, claudicants, and grafted arteriopaths

BACKGROUND: Recent data indicate that intermittent pneumatic compression (IPC) of the foot may offer benefits in patients with intermittent claudication exceeding those of standard medications approved by the Food and Drug Administration. IPC of the foot (IPC(foot)) and calf (IPC(calf)) increases flow velocity in infrainguinal arterial bypass grafts and thus may prevent arterial thrombosis. Our aim was to evaluate the acute effects of IPC of the thigh (IPC(thigh)), IPC(calf), and IPC of the thigh and calf (IPC(calf + thigh)) in healthy controls, claudicants, and arteriopaths who have undergone infrainguinal bypass grafting for critical or subcritical limb ischemia. METHODS: Sixteen limbs of normals (group A), 17 limbs of claudicants (group B), and 16 limbs of arteriopaths (group C) who had undergone infrainguinal autologous revascularization were studied. Blood flow was measured in the limbs of normals and claudicants in the popliteal artery and in the grafts of revascularized limbs by using duplex ultrasonography. Mean velocity (mV), peak systolic velocity, end diastolic velocity (EDV), pulsatility index (PI), and volume flow (Q) were measured in the sitting position at rest and within 10 seconds from the delivery of IPC(thigh), IPC(calf), and IPC(calf + thigh), IPC was delivered at maximum inflation and deflation pressures of 120 mm Hg and 0 mm Hg, respectively; inflation and deflation times of 4 and 16 seconds, respectively; and a proximal inflate delay of 1 second (calf compression preceding that of thigh). RESULTS: In all 3 groups with all IPC modes, the Q, mV, and EDV increased while PI decreased (P <.05). IPC(thigh) was less effective than IPC(calf), but still increased Q (by 114%, 57%, and 59.8% in groups A, B, and C, respectively) and EDV, while decreasing PI in all 3 groups (P <.05). IPC(calf + thigh) was the most efficient mode, generating an increase in the median Q of 424% in controls, 229% in claudicants, and 317% in grafted arteriopaths. The addition of IPC(thigh) to IPC(calf) increased the mV and Q in group A (P < or = .044); the mV, Q, and EDV in group B (P < or = .03), and mV and PI by 24% and -27% in group C, respectively. CONCLUSIONS: IPC applied to the thigh, either alone or in combination with IPC(calf), generates native arterial and infrainguinal autologous graft flow enhancement. The paucity of conservative methods available for lower limb blood flow augmentation may allow IPC of the lower limb to emerge as a reliable, noninvasive therapeutic option, ameliorating claudication and assisting infrainguinal bypass graft flow. IPC(thigh) adds to the armamentarium of currently known IPC options (foot or calf) promoting its applicability and efficacy.     

Effect of surgery on the systemic inflammatory response to intermittent claudication

The hypothesis that intermittent claudication initiates a systemic inflammatory response was investigated by studying the effect of exercise on markers of neutrophil activation and vascular permeability in 25 claudicants and 10 controls. Urinary albumin excretion, previously demonstrated to reflect vascular permeability, increased significantly after exercise in claudicants and was associated with decreased neutrophil filterability and increased serum lysozyme activity. No similar exercise-induced changes were seen in controls or in claudicants after successful arterial bypass surgery. These results suggest that intermittent claudication is associated with potentially deleterious systemic manifestations that are surgically reversible.     

Prevalence and Distribution of Coronary Disease in Claudicants Using 12-Lead Precordial Stress Electrocardiography

AIMS: to evaluate the prevalence of coronary artery disease (CAD) by means of modified stress electrocardiography in patients presenting with intermittent claudication. METHODS: three hundred consecutive patients (188 male) with intermittent claudication (post-exercise ankle brachial index <0.8), and 100 age and sex-matched controls, were assessed for CAD with resting and stress 12-lead-precordial ECG. A history of angina and previous myocardial infarction (MI) was recorded. Exclusion criteria: recent (<1 month) MI; unstable angina; prior coronary intervention; arrhythmias; conduction abnormalities; uncontrolled hypertension; heart failure, digoxin therapy, and inability to perform tests. RESULTS: based on antecedent angina, MI and abnormal resting ECG, CAD prevalence was 47% in claudicants and 6% in controls; on 12-lead-precordial ECG stress testing, CAD prevalence was 46% (95% CI: 40.1-51.7%) in claudicants and 11% (95% CI: 4.8-17.2%) in controls (both p <0.0001). Only 67% of claudicants (n=141) with antecedent angina, MI or an abnormal resting ECG, met the criteria of CAD on stress testing; also 28% of claudicants without antecedent angina, MI and a normal resting ECG (n=159) had evidence of CAD. The odds ratio for CAD in claudicants was 6.9. Based on 12-lead-precordial ECG stress testing we detected the presence of: one-, two- and three-vessel disease in 14.7% (95% CI: 10.6-18.7%), 19% (95% CI: 14.5-23.5%) and in 12.3% (95% CI: 8.6-16%) of claudicants; and in 8, 3 and 0% of controls, respectively. CONCLUSIONS: forty six percent of patients with intermittent claudication had concomitant CAD, and 31% two- or three-vessel disease. In the presence of claudication the odds ratio for CAD is 6.9 (95% CI: 3.5-13.4) and for two- or three-vessel disease 14.8. Non-invasive modified stress electrocardiography by enabling identification of those with multi-vessel CAD and thus by providing cardiac risk stratification may help bridge the gap between clinical evaluation and invasive coronary imaging.     

The fate of patients with intermittent claudication-comparison of surgical and non-surgical treatment]

The purpose of this study was to determine the operative indication for patients with intermittent claudication because of arteriosclerosis obliterans, and to compare the late result of the surgical treatment group (182 cases, 250 limbs) with that of the non-surgical treatment group (35 cases, 43 limbs). There were 3 operative deaths and 34 late deaths in the surgical group, and 14 late deaths in the non-surgical group. The number one cause of death was heart failure, including ischemic heart disease, in both groups. The 4-year cumulative patency rates were 91% in the aorto-iliac, 71% in the femoro-distal and 79% in the aorto-femoro-distal arterial reconstructions. Long term symptom free rates of the surgical group and the non-surgical group, except fatal case, were 83% and 44% in the aorto-iliac, 79% and 27% in the femoro-distal, 87% and 33% in the aorto-femoro-distal arterial regions, respectively. Late result of intermittent claudication in the surgical group was better than that in the non-surgical group. We concluded that intermittent claudication should be considered to be the indication for surgery, except for the cases with high risk diseases or malignant diseases.     

The fate of patients with intermittent claudication--comparison of surgical and non-surgical treatment

The purpose of this study was to determine the operative indication for patients with intermittent claudication because of arteriosclerosis obliterans, and to compare the late result of the surgical treatment group (130 cases, 175 limbs) with that of the non-surgical treatment group (27 cases, 31 limbs). There were 3 operative deaths and 21 late deaths in the surgical group, and 11 late deaths in the non-surgical group. The number one cause of death was heart failure, including ischemic heart disease, in both groups. The 5-year cumulative patency rate was 92.5% in the aorto-iliac, 70.6% in the femoro-distal and 82.0% in the aorto-femoro-distal arterial reconstructions. Long term symptom free rates of the surgical group and the non-surgical group, except fatal cases, were 87.2% and 25.0% in the aorto-iliac, 57.7% and 25.0% in the femoro-distal, 86.7% and 0% in the aorto-femoro-distal arterial regions, respectively. Late result of intermittent claudication in the surgical group was better than that in the non-surgical group. We conclude that intermittent claudication should be considered to be the indication for surgery, except for the cases with high risk diseases or malignant diseases.     

Realistic expectations for the patient with intermittent claudication

To determine the natural history of intermittent claudication 112 patients were followed for a minimum of 5 years and a median period of 82 months. Thirty-seven patients (33 per cent) died during the study period. Myocardial infarction (44 per cent) and cerebrovascular disease (28 per cent) were the most common causes of death. Overall mortality rate was 8, 23 and 40 per cent, at 2, 5 and 8 years respectively. Initial ankle-brachial pressure index (ABPI) correlated with subsequent death. With an initial ABPI less than 0.5 death occurred in 20, 50 and 69 per cent at 2, 5 and 7 years respectively, compared with 5, 16 and 24 per cent respectively for those with an initial ABPI greater than or equal to 0.5 (P less than 0.0001). Of the survivors only 21 per cent had worsening claudication and 13 per cent progressed to critical ischaemia. Arterial bypass for limb salvage was required in eight patients and four limbs were lost during the study period. ABPI identifies a subgroup of claudicants with an extremely high risk of death from coronary and/or cerebral pathology. In this subgroup an aggressive approach to the correction of atherosclerotic risk factors, rather than emphasis on the peripheral vascular problem alone, may improve survival.     

Femoropopliteal and femorotibial arterial reconstructive surgery. Special reference to the autogenous venous bypass procedure using unreversed vein after eversion valvectomy.

The outcome of 127 femoropopliteal and 23 femorotibial arterial reconstructions carried out between January 1960 and December 1972 has been reviewed. The operative method was autogenous saphenous vein bypass in 109 cases, 82 of which were performed using unreversed vein with eversion valvectomy. The indication for reconstruction was advanced ischemia in 39%. Two patients died primarily and 23 late deaths have occurred subsequently. 19 grafts or reconstructed segments became occluded primarily. Most of them were femorotibial reconstructions of Dacron bypass reconstructions. Most of the failures occurred within 1 year of surgery. Using eversion valvectomy technique, the 1- and 5-year patency rates were 57 and 50% respectively. In femorotibial reconstructions the 1-year patency rate was 36%. There was a distinct difference in patency between the cases with excellent of good outflow and those with fiar or poor outflow. The difference was less distinct between patients with claudication and those with advanced ischemia. Eight limbs needed major amputation.     

In situ saphenous vein bypass grafts for limb salvage: A current fad or a viable alternative to reversed vein bypass grafts?

Revascularization of the lower extremity using the in situ saphenous vein bypass graft has resurfaced as a clinical alternative to reversal of the saphenous vein. Early patency rates have been excellent, however, concern has been raised about the durability of the in situ technique. Our total experience with this technique has been reviewed to evaluate its effectiveness on a teaching vascular service. Seventy-six limbs in 71 patients were revascularized using the in situ technique. The distal anastomosis was created at the below-the-knee popliteal level in 26 limbs and at the infrapopliteal level in 50 limbs. Operative assessment of the vein quality showed 42 percent to be phlebitic or less than 4 mm in diameter. Hospital mortality was 0 and late mortality was 8 percent. Cumulative life table analysis showed the graft patency rate to be 89 percent 1 month postoperatively, 82 percent at 1 year, 77 percent at 2 years, and 72 percent up to 4 year postoperatively. Patency was independent of runoff to the pedal arch and the level of the distal anastomosis. Limb salvage at 4 years was 83 percent for distal popliteal grafts and 79 percent for infrapopliteal reconstructions. Our results indicate that the long-term durability of the in situ saphenous vein graft is excellent despite suboptimal veins and poor runoff. When performed properly, it is the preferred technique for arterial reconstruction below the knee joint.     

Should polytetrafluoroethylene grafts be used in preference to saphenous vein for femoropopliteal arterial bypass?

Some surgeons have advocated using polytetrafluoroethylene (PTFE) as the graft material of choice for femoropopliteal arterial bypass so that the saphenous vein could be preserved for future cardiovascular surgery. We have examined our results to see if this approach could be justified in our patient population. PTFE was used for 101 femoropopliteal reconstructions in 96 patients (56 male and 40 female). Thirty-eight (40%) complained of debilitating claudication and 58 (60%) had limb-threatening ischaemia. There were 83 primary PTFE femoropopliteal reconstructions and 18 repetitive procedures after failure of an earlier ipsilateral bypass. Twenty-nine of the 101 PTFE grafts were anastomosed distally to the popliteal artery above knee and the remaining 72 below knee. At 5 years, the cumulative patency for all grafts was only 11%. The 4 year cumulative patency was better for claudicants (40%) than for those with threatened limb loss (11%) but two of the 38 claudicants required amputation when their grafts failed. Patency rates were not significantly affected by the site of the distal anastomosis or by a previous failed ipsilateral femoropopliteal bypass. Worthwhile limb salvage was achieved only by frequent re-operation. Our results with PTFE are not good enough to use it in preference to an adequate saphenous vein for femoropopliteal bypass.     

Effect of intermittent pneumatic foot compression on popliteal artery haemodynamics.

PURPOSE: the aim was to investigate the effect of intermittent pneumatic foot compression (IPC(foot)) on popliteal artery haemodynamics in normal individuals and in patients with intermittent claudication due to peripheral vascular disease (PVD) (Fontaine stage II). MATERIAL AND METHODS: popliteal artery volume flow [vFl], pulsatility index [PI], mean velocity [mV], peak systolic [PSV] and end diastolic velocity [EDV], in 25 limbs of 20 normal subjects and 40 limbs of 32 stable claudicants were obtained in the sitting position before, during and within 30 seconds after the application of IPC(foot)(applied pressure: 120 mmHg; inflation time: 3 seconds; deflation time: 17 seconds) using colour-flow duplex imaging (CFDI). The reproducibility of flow velocity estimations using CFDI in the horizontal [hor] (recovery) and sitting [sit] positions was evaluated in 20 limbs of normal controls and 20 limbs of claudicants. RESULTS: popliteal artery vFl, mV, PSV and PI measurements were performed with a coefficient of variation (CV) of less than 14.6% among claudicants and of less than 13.3% in normal subjects. EDV is the least reproducible parameter with an overall CV range of 10.2-21.5% in normal controls and 9.1-18.6% in arteriopaths. On application of IPC(foot)popliteal artery vFl increased by 111% in the control group (p<0.001) and by 51% in the claudicants (p<0.001). Within 30 seconds of the cessation of pump action flow decreased significantly in both groups (p<0.001), but maintained a significantly higher level than that at baseline (p<0. 001, in both groups). The mV, PSV and EDV showed a similar pattern of significant changes. Both in normals and claudicants, the PI decreased with IPC(foot)(p<0.001) and increased post-compression; however, it was significantly lower than baseline (p<0.005) within 30 seconds of impulse delivery. CONCLUSIONS: current CFDI technology enables a reproducible estimation of popliteal artery flow velocities. IPC(foot)can significantly augment arterial calf inflow on an acute basis both in normals and claudicants. The increase of EDV and decrease of PI indicate that attenuation of peripheral resistance to flow is the main mechanism underlying the popliteal artery vFl enhancement on application of IPC(foot). Prospective trials on the long-term effect of IPC(foot)in the management of patients with PVD are indicated from the results of this study.     

The acute effects of intermittent pneumatic foot versus calf versus simultaneous foot and calf compression on popliteal artery hemodynamics: a comparative study

INTRODUCTION: Intermittent pneumatic compression (IPC) is currently being investigated with respect to its effect on distal arterial volume flow in patients with peripheral vascular disease. Recently published data have shown a substantial acute enhancement in arterial calf inflow in response to IPC of the lower limb in both intermittent claudication and leg ischemia. PURPOSE: The aim of the study was to compare the immediate effects of intermittent pneumatic foot (IPC(foot)) versus calf (IPC(calf)) versus simultaneous foot and calf compression (IPC(foot+calf)) on popliteal artery hemodynamics in patients with intermittent claudication (Fontaine II) and in normal subjects, using duplex ultrasonography. For this purpose, 25 limbs of 20 healthy subjects (age range [mean], 51-74 [64] years) and 31 limbs of 25 claudicants (age range [mean], 56-81 [66.5] years; resting ankle-brachial indices, 0.38-0.75 [0.55]) were examined in the sitting position with and without IPC compression. RESULTS: Mean popliteal artery flow in healthy subjects increased by 98.8% on application of IPC(foot), 188% with IPC(calf), and 274% with IPC(foot+calf) (all P <.001). Mean flow in claudicants increased by 58% on application of IPC(foot), 132% with IPC(calf), and 174% with IPC(foot+calf) (all P <.001). The mean velocity, peak systolic velocity, and end diastolic velocity displayed a pattern of change similar to that for volume flow in both groups. Pulsatility index decreased in both groups on application of IPC; the lowest values were generated with IPC(foot+calf). CONCLUSION: Of the three compression modes investigated, IPC(foot+calf) was the most effective means of acutely augmenting arterial calf inflow in arteriopaths and normals. The significant increase in end diastolic velocity and decrease in pulsatility index indicate that peripheral vasodilatation is the central mechanism in this impulse-related flow augmentation. Prospective trials are indicated to determine the clinical potential of the long-term effects of IPC(foot+calf) in patients with symptomatic peripheral vascular disease.     

Evaluation of the measurement of the intraoperative transcutaneous partial pressure of oxygen (PtcO2) as a prognostic indicator in vascular reconstruction

The intraoperative transcutaneous partial pressure of oxygen (PtcO₂) was used to monitor 58 vascular reconstructive surgery procedures in 54 patients. The study comprised three groups: Group A (24 limbs without any ischemic symptoms or signs), Group B (45 limbs with intermittent claudication), and Group C (12 limbs with ischemic rest pain, ulceration, and gangrene). In addition in 31 patients the chest wall was monitored simultaneously as a control. The results showed that the PtcO₂ values increased immediately and significantly to varying degrees and at varying speeds after unclamping. The controls had higher values than Group A (P>0.05), Group B (P<0.05), and Group C (P<0.05) patients. Further study showed that there were no significant differences between the maximal values in the limbs with good distal vessel run-off in Groups A, B, and C, and in the controls (P>0.05). It is thus concluded that effective vascular reconstruction in the limbs is indicated by a rapid and marked increase of both the PtcO₂ value and the response value, while with a slow and low increase of the value, early graft failure and poor distal vessel run-off should be suspected. We believe that this monitoring method dynamically reflects the functional state during vascular reconstruction and is clinically valid.     

Risk factors affecting the natural history of intermittent claudication

To determine the prognostic significance of the level of arterial disease in claudicators, risk factors affecting the progression of intermittent claudication, including hemodynamic variables obtained from noninvasive vascular laboratory examinations, were assessed. We identified 378 patients with intermittent claudication by characteristic history and the presence of abnormal treadmill exercise examination results. Results of serial examinations were available for 195 of these patients, who had 310 claudicating limbs. Life-table analysis revealed that after eight years, 41% of these patients had progressed to critical ischemia, defined as rest pain or tissue loss, and 50% had died. Cox proportional hazards general linear regression analysis found that at a patient's first examination in the vascular laboratory, the ankle-brachial index and the decrease in ankle-brachial index after exercise were significantly associated with the subsequent development of critical ischemia. The level of disease at the initial examination in the vascular laboratory was not a significant risk factor for progression to critical ischemia and therefore should not be used as an indicator for or against operation in patients with intermittent claudication.     

Reconstructive arterial surgery in peripheral obliterative atherosclerosis.

A series of 547 patients (678 extremities) subjected to reconstructive arterial surgery is presented, with a minimum observation period of 2 years. The incidence of associated diseases at the time of operation was high (39%) and accounted for an impressive mortality when the patients were observed for a longer period of time. The main indication for all types of reconstructions was intermittent claudication and the results are in accord with those reported in other larger series. In 244 patients subjected to open thrombendarterectomy the postopertive mortality was 10/244, with 55% of the reconstructions being open after a mean observation period of 76 months. In 158 patients undergoing femoro-popliteal vein bypass procedures, the postoperative mortality was 2/158, with 55% open grafts after a mean observation period of 61 months.     

Comparison of results in endovascular interventions for infrainguinal lesions: claudication versus critical limb ischemia

This study analyzed clinical success, patency, and limb salvage after endovascular repair in patients treated for chronic limb ischemia presenting with claudication versus critical limb ischemia. Between October 2001 and August 2004, 115 patients (mean age 71) underwent endovascular treatment for infrainguinal arterial disease. Techniques included subintimal angioplasty and transluminal angioplasty with or without stents. Lesions were classified according to Transatlantic InterSociety Consensus. Follow-up (mean 11 months) included physical exam, ankle-brachial index, and duplex ultrasound. Patency rates were determined using Kaplan-Meier and compared by log-rank analysis. One hundred ninety-nine lesions were treated in 121 limbs using percutaneous techniques. Comorbidities were similar except higher rates of diabetes mellitus (67% vs 41%, P < 0.001) and chronic renal insufficiency (22% vs 7%, P < 0.05) were found in critical limb ischemia patients. Primary patency for claudicants was 100 per cent, 98 per cent, and 85 per cent at 3, 6, and 12 months and 89 per cent, 80 per cent, and 72 per cent for critical limb ischemia, respectively (P = 0.06). Limb salvage was 91 per cent at 12 months for critical limb ischemia patients. Morbidity was similar between groups, and there was no perioperative mortality. Percutaneous intervention for both claudication and critical limb ischemia provides acceptable 12 month patency with limited morbidity.     

The effect of peripheral percutaneous transluminal angioplasty on quality of life in patients with intermittent claudication.

BACKGROUND AND OBJECTIVE: intermittent claudication is associated with a significant reduction in quality of life. Treatment of claudicants aims to reduce mortality from cardio- and cerebro-vascular events and to improve quality of life. Quality of life assessment should be used to guide and evaluate treatment in this group of patients. Peripheral percutaneous transluminal angioplasty (PTA) is now widely used in the treatment of intermittent claudication. The aim of this review is to examine the effect of PTA on quality of life (QOL) in patients with intermittent claudication. METHODS: a review was conducted of prospective clinical trials assessing the effect of peripheral PTA on QOL. Publications were retrieved by searching Medline and PreMedline, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of systematic reviews, AMED and CINAHL. The reference lists of the relevant publications were also searched. RESULTS: seven prospective studies (10 publications) on the effect of PTA on QOL in claudicants were identified. Several different questionnaires were used to measure quality of life (Nottingham Health Profiile, SF-36, EuroQol) none of which were disease specific. All the studies showed some improvement in QOL after PTA at follow-up periods of between 6 weeks and 24 months, except for one which showed some improvement at 6 months but not at 24 months. CONCLUSIONS: despite the fact that studies on the effect of PTA on QOL in claudicants have used generic QOL questionnaires which are relatively insensitive, the findings suggest that PTA may result in some improvement in QOL in these patients, although level I evidence to support this is lacking. The availability of disease-specific questionnaires should enable a more accurate assessment of PTA on QOL in these patients.     

Peripheral blood flow rates and microvascular responses to orthostatic pressure changes in claudicants before and after revascularisation.

OBJECTIVES: To study the effect of arterial reconstruction for occlusive atherosclerotic disease with intermittent claudication on blood flow rate during rest and on microvascular responses to orthostatic pressure changes in the pulp skin of the first toe where arteriovenous anastomoses are numerous. MATERIAL: Eleven patients with Fontaine IIa claudication (ankle blood pressure index > 0.30) before and 7 (range: 2-11) months after intervention. METHODS: Blood flow rate was measured by the heat washout method with the toe at heart level and after passive lowering to 50 cm below this level using a Clark type electrode with thermostatically controlled cap that was fixed to the pulp of the first toe by adhesive tape. RESULTS: At heart level, blood flow rate was lower in claudicants before reconstruction as compared to a group of previously published control subjects (p = 0.0076, Wilcoxon), blood flow rate increased in claudicants from before to after intervention (p = 0.0128), and postoperative blood flow rate was like that of normals (N.S.). Before surgery, blood flow rate in claudicants increased in median with a factor of 1.79 during lowering (p < 0.0051). CONCLUSIONS: The disturbance of the microcirculatory responses to orthostatically induced pressure changes in claudicants reverted towards normal after arterial reconstruction.     

The effect of postoperative smoking on femoropopliteal bypass grafts

Effect of smoking habits on limb loss rates and cumulative patency rates of 136 arterial reconstructions performed for lower limb ischemia were analyzed in a five year follow-up retrospective study. Of 121 patients, 103 (85%) smoked before the operation and 43 of the smokers (42%) discontinued smoking postoperatively. Patients who continued to smoke more than 15 cigarettes per day (34 patients) increased the probability of losing their limb approximately five times at two years and three times at five years postoperatively, compared with nonsmokers and smokers of up to 15 cigarettes per day (87 patients) (p = 0.013). Cumulative patency rates of nonsmokers and smokers of up to five cigarettes per day (Group A, 66 patients) were not significantly influenced (p = 0.518) by preoperative symptoms (claudication versus limb salvage). However, for smokers of more than five cigarettes per day (Group B, 55 patients), at five years claudicants had a cumulative patency rate of 62.9% compared to 38.3% for limb salvage patients (p = 0.015). In group A at five years, autologous saphenous vein grafts had a cumulative patency rate of 74.2%, compared to 24% for prosthetic grafts (P = 0.013). In group B the CPR differences between autologous saphenous vein and prosthetic grafts were not significantly different (p = 0.394). Multiple interactions between smoking and variables like age, preoperative symptoms, and graft material demonstrate the complexity of the effects of smoking on cumulative patency rate and the need for sub-grouping and removal of confounding factors. In view of the adverse affects of continued smoking on postrevascularization prognosis, patients should be strongly advised to discontinue smoking.     

Mean Flow Measurements in Aortofemoral Arterial Reconstructions

Eighty-seven limbs in 48 patients have been studied with an electromagnetic flow meter at the time of arterial reconstruction designed to restore blood flow from the aorta to the femoral artery system. The mean overall flow was 339 ml per minute. Blood flow in aneurysmal disease was significantly higher than that recorded in obstructive disease. Blood flow in arteries running into a fully patent femoral system was significantly higher than in those that ran only into the profunda. Age, sex, type of surgery and size of graft had no influence on the flow achieved. Reconstructions for rest pain or advanced trophic change produced flows of the same magnitude as reconstructions for intermittent claudication. The patient's weight correlated significantly with the intraoperative flow. The mean flow in the limbs of 28 patients in whom an accurate preoperative weight was known was 2–56 mil 100 gm/minute, taking the hind limb and hemi-pelvis as 25% of the body weight. This is an acceptably “normal” value. A flow of less than 100 ml per minute in an aortoiliac reconstruction was found to be not likely to result in long-term patency.