Unilateral Leg Oedema in Association with an Aortocaval Fistula

The study considers a case of a patient who presented with scrotal and unilateral leg oedema secondary to an aortocaval fistula (ACF) complicating an abdominal aortic aneurysm (AAA). During the operation, caval blood loss was controlled with digital pressure over the fistula, and direct closure performed using a 3/0 prolene suture. The aneurysm repair was carried out with a woven Dacron^® graft. The possibility of an ACF in the presence of AAAs should be considered when examining a patient with intractable unilateral leg oedema. The successful outcome depends on early preoperative recognition, prompt surgical repair and careful attention to intra-operative blood loss.     

Multiple aortocaval fistulas associated with a ruptured abdominal aneurysm in a patient with Ehlers-Danlos syndrome.

Aortocaval fistula (ACF) is a rare complication of spontaneous abdominal aortic aneurysm (AAA) rupture, with an incidence of 2-4%. A unique case of ruptured AAA complicated by multiple aortovenous fistulas involving the inferior vena cava and left internal iliac vein is presented, and is the first published report of a patient with Ehlers-Danlos syndrome undergoing surgical treatment for an ACF.     

Stasis oedema in the elderly: are diuretics necessary?

Diuretic therapy was discontinued in 15 elderly patients. None of these patients had evidence of uncontrolled cardiac failure or hypertension, and they all had received diuretics long-term. Two patients required resumption of diuretics due to the development of cardiac failure or severe leg oedema. In the remaining 13 patients, mean leg volume increased by 8.2%. Discontinuation of diuretic therapy in elderly patients is associated with a small but significant worsening of lower limb oedema.     

Refractory oedema in congestive heart failure: a contributory role of loop diuretics

Abstract. We report a patient with congestive heart failure (CHF) who presented with massive oedema resistant to therapy with maximal doses of loop diuretics, despite an adequate renal function. After a diuretic pause and dietary salt restriction, a conventional dose of furosemide in combination with distally active diuretics induced a prompt weight loss exceeding 30 kg with stable renal function. We suggest that the ‘refractory’ oedema in this patient was due to a combination of CHF and inappropriate (loop) diuretic therapy in conjunction with a high dietary sodium intake. We conclude that in the absence of hyponatraemia and renal failure, even severe oedema may not represent a negative prognostic indicator. The recognition of diuretic-associated mechanisms complicating cardiac oedema is essential to avoid the vicious circle of worsening oedema whilst escalating therapy with loop diuretics.     

Exercise training improves exertional dyspnea in patients with COPD: evidence of the role of mechanical factors

BACKGROUND: To our knowledge, no data have been reported on the effects of exercise training (EXT) on central respiratory motor output or neuromuscular coupling (NMC) of the ventilatory pump, and their potential association with exertional dyspnea. Accurate assessment of these important clinical outcomes is integral to effective management of breathlessness of patients with COPD. MATERIAL AND METHODS: Twenty consecutive patients with stable moderate-to-severe COPD were tested at 6-week intervals at baseline, after a nonintervention control period (pre-EXT), and after EXT. Patients entered an outpatient pulmonary rehabilitation program involving regular exercise on a bicycle. Incremental symptom-limited exercise testing (1-min increments of 10 W) was performed on an electronically braked cycle ergometer. Oxygen uptake (O(2)), carbon dioxide output (CO(2)), minute ventilation (E), time, and volume components of the respiratory cycle and, in six patients, esophageal pressure swings (Pessw), both as actual values and as percentage of maximal (most negative in sign) esophageal pressure during sniff maneuver (Pessn), were measured continuously over the runs. Exertional dyspnea and leg effort were evaluated by administering a Borg scale. RESULTS: Measurements at baseline and pre-EXT were similar. Significant increase in exercise capacity was found in response to EXT: (1) peak work rate (WR), O(2), CO(2), E, tidal volume (VT), and heart rate increased, while peak exertional dyspnea and leg effort did not significantly change; (2) exertional dyspnea/O(2) and exertional dyspnea/CO(2) decreased while E/O(2) and E/CO(2) remained unchanged. The slope of both exertional dyspnea and leg effort relative to E fell significantly after EXT; (3) at standardized WR, E, and CO(2), exertional dyspnea and leg effort decreased while inspiratory capacity (IC) increased. Decrease in E was accomplished primarily by decrease in respiratory rate (RR) and increase in both inspiratory time (TI) and expiratory time; VT slightly increased, while inspiratory drive (VT/TI) and duty cycle (TI/total time of the respiratory cycle) remained unchanged. The decrease in Pessw and the increase in VT were associated with lower exertional dyspnea after EXT; (4) at standardized E, VT, RR, and IC, Pessw and Pessw(%Pessn)/VT remained unchanged while exertional dyspnea and leg effort decreased with EXT. CONCLUSION: In conclusion, increases in NMC, aerobic capacity, and tolerance to dyspnogenic stimuli and possibly breathing retraining are likely to contribute to the relief of both exertional dyspnea and leg effort after EXT.     

Abdominal aortic aneurysm associated with abdominal visceral diseases

Abdominal aortic aneurysm (AAA) occurs in advanced age. As such, its frequency has increased with the general ageing of the population as has the possibility of finding AAA associated with abdominal visceral disease, especially neoplasms. A malignant mass is present in 4% of patients who undergo aortic reconstruction for AAA. Since surgical treatment for both is often potentially life-threatening, the surgeon is faced with a series of treatment decisions concerning foremost timing of the operation. The main worry is that simultaneous treatment carries a potential risk of infection of the vascular graft. On the other hand, a 2-phase procedure is also burdened by risks linked to a second anaesthesia and a second surgical operation carried out on scar or contaminated tissue and the worsening of one of the 2 potentially life-threatening illnesses. In this situation endovascular treatment of an AAA may represent an advantageous alternative therapeutic strategy.     

Very large pericardial effusion attributable to minoxidil: resolution without drainage of fluid

A 52-year-old man with a history of chronic hypertension presented with worsening dyspnea and leg edema. He had been on minoxidil for 10 years. The cardiac silhouette was markedly enlarged. Echocardiography and computed tomography showed a large pericardial effusion. His cardiac status was stable and he was in no cardiorespiratory distress. No attempt was made to drain the fluid. Minoxidil was discontinued, and a month later, the effusion had virtually disappeared. Cessation of minoxidil administration and conservative management may suffice, even though the pericardial effusion is large.     

Quantification of leg oedema in postmenopausal hypertensive patients treated with lercanidipine or amlodipine

OBJECTIVE: Of the study was to compare the leg oedema-forming potential of two different dihydropyridine calcium channel blockers in postmenopausal women. DESIGN: A total of 92 postmenopausal hypertensive patients [systolic blood pressure (SBP) 150-179 mmHg or diastolic blood pressure (DBP) 95-109 mmHg were randomized to receive a 4-week treatment with either 10 mg/day lercanidipine (n = 48) or 5 mg/day amlodipine (n = 44), with force-titration to 20 and 10 mg/day, respectively for an additional 4 weeks. METHODS: Leg volume was measured by water displacement volumetry, patients were questioned for symptoms and a physical examination was performed to detect the presence of oedema. RESULTS: A total of 77 patients completed the study, without a major protocol violation and were included in the primary analysis. Leg volume increase from baseline was significantly higher in the amlodipine than in the lercanidipine group (60.4 +/- 8.6 versus 5.3 +/- 8.1 ml; P < 0.001). The percentage of patients with evidence of oedema on physical examination (33.3 versus 9.8%, P = 0.011) and with symptoms of leg swelling (63.9 versus 22%, P < 0.001) and leg heaviness (47.2 versus 12.2%, P < 0.001) was also greater with amlodipine compared with lercanidipine. A positive correlation was found between leg volume and sign or symptoms of oedema (P < 0.001). Both drugs reduced SBP and DBP, with no significant differences between treatments. No correlation was found between leg volume changes from baseline and the antihypertensive effect of either drug. CONCLUSIONS: In postmenopausal females with mild to moderate hypertension the oedema formation of Lercanidipine was significantly less than that of Amlodipine, despite no significant differences in the antihypertensive effect.     

Exercise capacity and ventilatory, circulatory, and symptom limitation in patients with chronic airflow limitation.

Dyspnea, leg effort (Borg 0 to 10 scale), ventilation, and heart rate (VEmax/VEcap; HRmax/HRcap expressed as a percentage of capacity) were measured at maximal exercise (cycle ergometer) in 97 patients with chronic airflow limitation (CAL) (FEV, 46.6 +/- 14.23% of predicted) and compared with 320 matched control subjects. Patients with CAL achieved a maximum power output of 86 +/- 39.5 W (60 +/- 23.2% of predicted) compared with 140 +/- 37.5 W (98 +/- 14.5% of predicted) in controls (p less than 0.0001), VEmax/VEcap was 72 +/- 19.3% compared with 53 +/- 18.6% (p less than 0.0001), and HRmax/HRcap was 76 +/- 13.5% compared with 82 +/- 13% (p less than 0.001). These findings were expected. The median intensity of dyspnea was 6 (severe to very severe) and leg effort was 7 (very severe) in both groups, and these findings were unexpected. The patients with CAL were handicapped by an increase in both dyspnea and peripheral muscular effort relative to the actual power output. The rating of dyspnea exceeded leg effort in 25 (26%) of CAL versus 69 (22%) control subjects: the rating of leg effort exceeded dyspnea in 42 (43%) CAL and 117 (36%) control subjects; both were rated equally in 30 (31%) CAL and 134 (42%) control subjects, respectively (NS). VEmax/VEcap and HRmax/HRcap were not significantly different in those limited by dyspnea, leg fatigue, or a combination of both. All values are expressed +/- SD.     

Clinical features of venous insufficiency and the risk of venous thrombosis in older people

Venous thrombosis is common in older age, with an incidence of 0·5–1% per year in those aged >70 years. Stasis of blood flow is an important contributor to the development of thrombosis and may be due to venous insufficiency in the legs. The risk of thrombosis associated with clinical features of venous insufficiency, i.e., varicose veins, leg ulcers and leg oedema, obtained with a standardized interview was assessed in the Age and Thrombosis Acquired and Genetic risk factors in the Elderly (AT‐AGE) study. The AT‐AGE study is a case–control study in individuals aged 70 years and older (401 cases with a first‐time venous thrombosis and 431 control subjects). We calculated odds ratios (ORs) and corresponding 95% confidence intervals (CI) adjusted for age, sex and study centre. Varicose veins and leg ulcer were associated with a 1·6‐fold (95% CI 1·2–2·3) and 3·3‐fold increased risk of thrombosis (95% CI 1·6–6·7), respectively, while the risk was increased 3·0‐fold (95% CI 2·1–4·5) in the presence of leg oedema. The risk of thrombosis was highest when all three risk factors occurred simultaneously (OR: 10·5; 95% CI 1·3–86·1). In conclusion, clinical features of venous insufficiency, i.e., varicose veins, leg ulcers and leg oedema, are risk factors for venous thrombosis in older people.     

Portable ultrasound assessment of bone in the elderly: hemiparesis following stroke as a model for disuse osteoporosis

To evaluate portable bone ultrasound as a technique for the assessment of osteoporosis in disabled and elderly subjects we have used hemiparesis following stroke as a model for disuse osteoporosis. We used the CUBA clinical system in a cross-sectional study of 38 stroke unit and day hospital patients, at an average of 8 months after stroke. On average broadband ultrasound attenuation (BUA) was lower by 5.5 dB MHz(-1) in the hemiparetic (mean 65.9 dB MHz(-1)) compared to the normal limb (mean 71.4 dB MHz(-1)). This was significant at P<0.05 on paired t-test, but appears to reflect the presence of oedema in the weak leg. A total of 16 (42%) of our subjects had such oedema and these subjects showed a larger BUA difference of 9.2 dB MHz(-1). A total of 22 subjects without leg oedema showed a smaller BUA difference (2.8 dB Mhz(-1)). This result is similar to the difference in bone density described in previous work using dual-energy X-ray absorptiometry (DXA) after stroke, but did not achieve statistical significance (P=0.4). Bone ultrasound scanning was simple and acceptable to our subjects, but sensitivity to the presence of oedema may limit its precision in work with disabled and elderly subjects.     

Arm exercise capacity and dyspnea ratings in subjects with chronic obstructive pulmonary disease

PURPOSE: This study aimed to compare the metabolic, ventilatory, and dyspnea responses to unsupported arm exercise, supported arm exercise and leg exercise between subjects with chronic obstructive pulmonary disease (COPD) and healthy age-matched controls. METHODS: For this study, 21 subjects with COPD (mean age, 62 +/- 2 years; predicted forced expiratory volume in 1 second [FEV(1)], 37 +/- 3%) and 7 healthy age-matched control subjects (% pred FEV(1) = 109 +/- 5%) were included in the analyses of three incremental exercise tests to peak work capacity: unsupported arm exercise, supported arm exercise (arm ergometry), and leg exercise (cycle ergometry). Work level, oxygen consumption (VO(2)), minute ventilation (V(E)), dyspnea, and rate of perceived exertion were measured each minute. RESULTS: Peak work level and peak VO(2) were significantly reduced in the subjects with COPD for all exercise tests (P <.01 for all), as compared with the control subjects. Within the COPD group, the VO(2) and V(E) at peak exercise were significantly lower for unsupported arm exercise than for both the leg and supported arm exercises (both P <.001). The ratio of V(E) to maximal voluntary ventilation was high for leg exercise (96%), supported arm exercise (91%), and unsupported arm exercise (77%) among the subjects with COPD. At a given percentage of VO(2) peak, dyspnea scores were similar for all the exercise tests. CONCLUSIONS: Ventilatory constraints limit exercise performance in COPD. The lowest amount of work, in terms of VO(2,), was during unsupported arm exercise. Because the subjects with COPD had scores showing similar levels of dyspnea at the same percentage of VO(2) peak, it is suggested that patients be encouraged to reach equivalent dyspnea levels when performing unsupported and supported arm exercise training and leg training.     

Selective low-level leg muscle training alleviates dyspnea in patients with heart failure

OBJECTIVES: The purpose of this study was to demonstrate in patients with moderate to severe heart failure that exertional dyspnea can be alleviated by improving muscle function. BACKGROUND: Dyspnea is a frequent limiting symptom in patients with chronic heart failure (CHF). This sensation may originate from activation of receptors in the musculature rather than the lung. METHODS: To investigate whether dyspnea could be alleviated by selective changes in leg muscle function, we performed isolated lower-limb training in 17 patients with severe CHF. Eight patients learned guided imagery relaxation techniques and served as an active control group. Exercise training consisted of three months of low-level bicycle and treadmill exercise such that minute ventilation was <25 l/min. Leg calisthenics were also performed. Maximal and submaximal exercise performance, respiratory and quadriceps muscle strength and endurance and quality-of-life and dyspnea scales were measured before and after each intervention. Metabolic stress testing (VO(2)), pulmonary function tests and isokinetic strength testing were also performed. RESULTS: In the active control group, no changes in leg muscle function, pulmonary function, maximal and submaximal exercise performance or quality-of-life questionnaires were observed. In the training group, peak torque of leg flexors (pre: 39 +/- 15 ft-lb; post: 50 +/- 13 ft-lb; p < 0.002) increased and the fatigue ratio decreased, indicating improved strength and endurance of the leg muscles. Maximal inspiratory and expiratory mouth pressures and maximum voluntary ventilation were unchanged. Peak VO(2) was increased (pre:12 +/- 2.2 ml/kg/min; post: 14 +/- 2.6 ml/kg/min) as well as the duration of exercise at 70% peak VO(2) increased (pre: 11.5 +/- 3.1 min; post: 21.5 +/- 5.4 min; p < 0.003). Perceived dyspnea during the submaximal testing was decreased. Minnesota Living with Heart Failure Score, Guyatt Dyspnea Scale, and the Transitional Dyspnea Index were all improved with training (all p < 0.05). CONCLUSIONS: We concluded that improvement of limb muscle function alleviates dyspnea and improves exercise performance in patients with CHF.     

Doxium 500 in chronic venous insufficiency: a double-blind placebo controlled multicentre study

The aim of this double-blind placebo-controlled study was to evaluate the therapeutic efficacy of Doxium in chronic venous insufficiency (CVI). 225 patients were treated randomly for 4 weeks with 1.5 g (3 capsules/day) of Doxium or placebo. The evolution of the leg oedema was determined by measuring calf and ankle circumferences. Pain and discomfort were assessed by visual analogue scale. The results show that at the end of the trial, all the examined parameters (leg oedema, pain, day and night cramps, discomfort, heavy legs, paresthesia and restless legs) were significantly more improved in the Doxium group than in the placebo group: the leg volume was diminished by 3.8% in the Doxium group compared to 1.2% in the placebo (p less than 0.005). The overall assessment by the physicians showed an improvement in 82% of the Doxium-treated patients compared to 42% of the placebo group (p less than 0.0001). The tolerance of the treatment was comparable in both groups.     

Improvement in quadriceps strength and dyspnea in daily tasks after 1 month of electrical stimulation in severely deconditioned and malnourished COPD

STUDY OBJECTIVES: Low body weight in COPD patients is associated with worsening dyspnea, reduced leg strength, and poor prognosis. Classical rehabilitation strategies are then limited by reduced exercise tolerance. Thus, we proposed to evaluate whether electrostimulation (ES) was a beneficial technique in the rehabilitation programs for severely deconditioned COPD patients after an acute exacerbation. DESIGN: Randomized, controlled study. SETTING: Pulmonary rehabilitation center. PATIENTS: Seventeen patients with severe COPD (mean [ +/- SD] FEV(1), 30 +/- 3% predicted) and low body mass index (BMI) [18 +/- 2.5 kg/m(2)]. METHODS: Patients were randomly assigned either to usual rehabilitation (UR) alone or to a UR-plus-ES program for 4 weeks. Quadriceps muscle strength, total muscle mass (MM), exercise capacity, and health-related quality of life were measured before and after rehabilitation. RESULTS: The training with ES plus UR induced a significant twofold improvement in the mean number of maximal voluntary contraction (MVC) compared to UR alone (97 +/- 71 vs 36 +/- 34 contractions, respectively; p = 0.03) and resulted in a more significant improvement in dyspnea when performing daily tasks (decrease in the dyspnea domain score of the 28-item Maugeri Foundation Respiratory Failure questionnaire, -1.7 +/- 1.0 vs -0.2 +/- 1.2 points, respectively; p = 0.05). There was also a significant increase in walking distance (63 +/- 40 m; p = 0.01) and BMI (0.6 +/- 0.5 kg/m(2); p = 0.02) after training in the ES + UR group. A significant relationship was found between changes in MVC and changes in MM after training in the ES + UR group (r = 0.94; p = 0.03). CONCLUSIONS: The combination of ES and UR was associated with greater improvement in quadriceps strength and dyspnea during the performance of daily tasks than UR alone in severely disabled COPD patients with low BMI. In this population, ES has been revealed as a useful procedure, complementing the usual pulmonary rehabilitation.     

Acquired aortocameral fistula occurring late after infective endocarditis: An emblematic case and review of 38 reported cases

AIM To delineate the features and current therapeutic option of congenital and acquired aortocameral fistulas(ACF) secondary to iatrogenic or infectious disorders.METHODS From a Pub Med search using the term "aortocameral fistula", 30 suitable papers for the current review were retrieved. Reviews, case series and case reports published in English were considered. Abstracts and reports from scientific meetings were not included. A total of 38 reviewed subjects were collected and analyzed. In addition, another case- an adult male who presented with ACF between commissures of the right and noncoronary sinuses and right atrium as a late complication of Staphylococcus aureus infective endocarditis of the AV- is added, the world literature is briefly reviewed.RESULTS A total of thirty-eight subjects producing 39 fistulas were reviewed, analyzed and stratified into either congenital(47%) or acquired(53%) according to their etiology. Of all subjects, 11% were asymptomatic and 89% were symptomatic with dyspnea(21 ×) as the most common presentation. Diagnosis was established by a multidiagnostic approach in 23(60%), single method in 14(37%)(echocardiography in 12 and catheterization in 2), and at autopsy in 2(3%) of the subjects. Treatment options included percutaneous transcatheter closure in 12(30%) with the deployment of the Amplatzer duct or septal occluder and Gianturco coil and surgical correction in 24(63%). CONCLUSION Acquired ACF is an infrequent entity which may occur late after an episode of endocarditis of the native AV. The management of ACF is generally by surgical correction but non-surgical device intervention has recently been introduced as a safe alternative.     

Atherosclerotic renovascular disease in chronic heart failure: should we intervene?

Renal artery stenosis (RAS) is most commonly caused by atherosclerosis, which is also the most common cause of chronic heart failure (CHF). One-third of patients with CHF are reported to have significant renovascular disease. The presence of RAS confers a worse outcome in studies of hypertension and coronary disease, though data are lacking for patients with CHF. As the kidney is intricately involved in the fluid retention that occurs in CHF, an adverse effect of RAS on outcome would be expected. Presentations of RAS in CHF include flash pulmonary oedema, hypertension, worsening of CHF, and worsening renal function. RAS commonly progresses and may cause worsening of renal function in patients with CHF and previously stable renal function. A variety of investigations that can safely and accurately identify RAS in CHF are available, although none is recommended in current guidelines for the management of CHF. Treatment for RAS, whether for hypertension, for renal dysfunction, or for pulmonary oedema, is at the discretion of the physician due to the lack of adequate randomized controlled trials demonstrating the efficacy and safety of intervention. As it is not clear how RAS should be managed in CHF, screening cannot be advocated. Currently, a multicentre randomized outcome trial, which includes a cohort of patients with RAS and CHF, is in progress to provide answers in this area of uncertainty.     

Decompensated heart failure: symptoms,patterns of onset,and contributing factors

PURPOSE: To examine the time course, contributing factors, and patient responses to decompensated heart failure. METHODS: We studied consecutive patients admitted to a public general hospital with a diagnosis of heart failure. Using a timeline follow-back technique, a nurse interviewer administered a questionnaire shortly after admission, exploring knowledge of a heart failure diagnosis, the symptoms and time course of decompensation, and patient responses to worsening symptoms. RESULTS: Of 87 patients, 83 (95%) consented to be interviewed. Only 49 (59%) were aware of the diagnosis of heart failure. Symptoms associated with decompensation included dyspnea in 81 patients (98%), edema in 64 patients (77%), and weight gain in 34 patients (41%). Onset of worsening of these symptoms was noted a mean (+/- SD) of 12.4 +/-1.4 days before admission for edema, 11.3 +/-1.6 days for weight gain, and 8.4 +/- 0.9 days for dyspnea. Forty-two patients (57%) reported missing or skipping medication because of various factors, particularly missed outpatient appointments. CONCLUSION: Using a timeline follow-back interview, we identified a period of days to weeks between the onset of worsening symptoms and hospital admission for heart failure decompensation. This pattern suggests that there is a time window between symptom exacerbation and admission during which earlier access and intervention might prevent hospitalization in these patients. Medication lapses continue to be an important preventable cause of decompensation leading to admission.     

CPAP increases exercise tolerance in obese subjects with obstructive sleep apnea

Obese subjects commonly suffer from exertional dyspnea and exercise intolerance. Preliminary evidence suggests that treatment with nocturnal continuous positive airway pressure (nCPAP) may improve dyspnea in obese patients with obstructive sleep apnea (OSA), but the effect on exercise tolerance is unknown. This study sought to investigate whether nCPAP improves exercise tolerance and exertional dyspnea in obese patients with OSA. Obese patients prescribed nCPAP for moderate/severe OSA and without cardiopulmonary disease were recruited. Patients completed a constant-load exercise test and Baseline and Transitional Dyspnea Index questionnaires (BDI/TDI) at baseline and after one and three months of nCPAP. Primary outcome was change in constant-load exercise time from baseline to one and three months. Secondary outcomes included changes in isotime dyspnea, isotime leg fatigue and BDI/TDI score at one and three months. Fifteen subjects (body mass index?=?43?kg?m(-2), apnea-hypopnea index?=?49(.)hr(-1)) were studied. Constant-load exercise time increased by 2.0?min (40%, p?=?0.02) at one month and 1.8?min (36%, p?=?0.04) at three months. At one and three months, isotime dyspnea decreased by 1.4 (p?=?0.17) and 2 units (p?=?0.04), and leg fatigue decreased by 1.2 (p?=?0.18) and 2 units (p?=?0.02), respectively. BDI/TDI scores were 2.7 (p?=?0.001) and 4.5 points (p?相似文献   

The distribution of oedema in the lower limb of patients with chronic critical limb ischaemia: a study with computed tomography

BACKGROUND: A substantial number of patients with chronic critical limb ischaemia (CLI) have considerable oedema at the distal leg and foot of non deep venous thrombosis origin. The primary aim of the present study was to quantify the distribution of oedema in the different tissues of the leg and foot by applying computed tomography and planimetry. The interstitial fluid hydrostatic pressure (Pif) in the subcutaneous tissue was measured to evaluate the effect of oedema on local tissue pressure. PATIENTS AND METHODS: Six men and 12 women with unilateral CLI and peripheral pitting oedema were included. Cross sectional areas (CSA) of subcutaneous tissue, muscle and bone were measured by computer tomography combined with planimetry to assess the distribution of oedema within the soft tissues. Pif was measured by "wick-in-needle" technique. RESULTS: The median total CSA of soft tissue, subcutaneous and muscle tissues at the foot level were respectively 17%, 34% and 9% greater in the limbs with CLI compared to the contralateral limb (p < 0.001). At ankle level these differences were 13%, 30% and 4%, respectively (p < 0.001). At the level of the calf these differences were not significant. Mean Pif in the limbs with CLI was 0.3 mmHg, significantly higher than in limbs without CLI (-1.8 mmHg), (p < 0.003). CONCLUSION: The study verified oedema of considerable magnitude at the ankle and foot. The great part of the oedema was located within the subcutaneous tissue, which was associated with a relatively moderate, but significant increase in Pif confirming the high compliance of the subcutaneous tissue. The combination of the excessive fluid and increased Pif in the interstitial tissue might aggravate the microcirculation. The aetiology of oedema formation is probably multifactorial.