Hyperhomocysteinemia in Patients with Arterial Occlusive Disease

PURPOSE: Hyperhomocysteinemia (HHCA) is defined as an independent risk factor for atherothrombotic vascular disease; therefore, screening for HHCA is recommended. However, the incidence and characteristics of HHCA in patients with vascular disease remain unclear. We conducted this study in an attempt to resolve these issues. METHODS: This nonrandomized prospective study included 56 patients who were admitted with occlusive arterial disease (group I), and 39 control patients without occlusive arterial disease (group II). We recorded all the demographic data of both groups and collected blood samples for fasting homocysteine, vitamin B(12), and folic acid. All of the patients were followed up and the results were compared. RESULTS: The mean concentration of homocysteine was 12.69 +/- 3.82 micromol/l in group I and 10.46 +/- 5.08 micromol/l in group II (P = 0.00048). In group I, the mean homocysteine levels for patients aged > or =70 years and those aged <70 years were 13.74 +/- 3.02 and 11.55 +/- 4.15 micromol/l, respectively (P = 0.021). There was no significant difference in mortality between the patients with HHCA and those with normal homocysteine levels during follow-up. CONCLUSION: The incidence of hyperhomocysteinemia was higher in the patients with occlusive vascular disease than in the control patients. More evidence of the association with vitamins B(12) and folate and the benefits of homocysteine-lowering therapy is needed since we found no relationship between these vitamins and homocysteine in this study.     

Increased Incidence of Lower Limb Amputation for Arterial Occlusive Disease

The number of amputations in Malmohus county with just over 500000 inhabitants had increased from 14 to 161 during the years 1910-79 measured each fifth year comprising totally 724 observations. the number of amputations compared to the age related incidence 1979 had increased four times. Age, diabetes mellitus and sex proportions of ischemic amputees were studied and compared to other Scandinavian reports over the last 30 years. the proportion of diabetic amputees (0.37) and the male proportion (0.54) seemed unchanged, but the proportion of amputees at least 80 years old had increased from about 0.09 to 0.38.     

Age, Diabetes and Smoking in Lower Limb Amputation for Arterial Occlusive Disease

The increased number of amputations for arterial occlusive disease noted in western countries is only partly explained by increasing numbers of the elderly. A prospective analysis of the influence of diabetes and smoking habits was therefore carried out. in 1978-81, 188 lower limb amputees in Lund were examined and classified as non-smokers, ex-smokers, light smokers and heavy smokers. These figures were compared with corresponding figures among age-correlated controls and to a group of hip fracture patients. the material was divided into men and women and into non-diabetics and diabetics. Smokers had much lower mean age at amputation. Out of 188 amputees only 23 were not either a diabetic, a smoker or 80 years or more. the population study indicates a correlation between smoking and amputation for ichaemia. the coincident increase in cigarette consumption in Sweden is illustrated and it is suggested that smoking should be noted as routinely as diabetes at amputations.     

Below-Knee Amputation in Peripheral Arterial Disease

A below-knee amputation will heal in most patients with atherosclerotic peripheral arterial disease, using no anterior flap and a long posterior myoplastic flap. The technique used by the authors is presented in detail, with their experience in 32 cases.     

Arterial Occlusive Disease of the Upper Extremity

Twenty-five upper extremities were operated upon in 24 patients because of arterial occlusive disease. Transthoracic endarterectomy was performed in 4 patients with short central occlusions of the subclavian artery. In the remaining patients, various bypass procedures were performed using reversed autogenous veins or prosthetic grafts. There were 2 early and 6 late deaths. One prosthetic graft had to be removed 2 months after the operation because of infection. At follow-up, 9 months to 17 years after surgery, 11 bypass grafts were patent. One vein graft and one prosthetic graft had occluded. The surgical technique, types of graft to be used, and the relation to long-term patency are briefly discussed.     

Endovascular Management of Brachiocephalic Arterial Occlusive Disease

Annals of Vascular Surgery -     

下肢多平面动脉闭塞症的动脉重建术

探讨下肢多平面动脉闭塞症近远端动脉重建的治疗经验。方法:全组18例,男15,女3,平均67.4岁。通过测定踝/臂指数和经皮动脉穿刺插管造影,确定动脉病变范围。一期实施近、远端动脉重建16例,股-胫后动脉旁路转流2例。结果:全组术前平均踝/臂指数0.4,主、髂、股动脉病变33.3％,股、腘、小腿动脉病变55.6％,髂-小腿全下肢动脉病变11.1％。术后病死率5.6％,截肢率11.1％。术后1月,静息痛症状均得到改善,肢端溃疡愈合,踝/臂指数平均值0.94。平均随访22.5月,近端动脉重建畅通率100％,远端动脉重建畅通率80％,踝/臂指数平均0.85。结论:下肢多平面动脉闭塞症同时行近远端动脉重建安全、有效。手术成功关键在于动脉重建流人、流出道的畅通。     

Level Selection in Leg Amputation for Arterial Occlusive Disease: A Comparison of Clinical Evaluation and Skin Perfusion Pressure

In 102 leg amputations for arterial occlusion including 84 below-knee (BK), 16 above-knee (AK) and 2 through-knee (TK) amputations, the amputation level was determined by means of clinical criteria. The healing results and the selection of levels were then compared with sealed preoperative measurements of the skin perfusion pressure (SPP). Out of 62 BK amputations with an SPP above 30 mmHg wound healing failed in only 2 cases (3 per cent). Out of 13 BK amputations with an SPP between 20 and 30 mmHg 7 cases (54 per cent) failed and out of 9 BK amputations with an SPP below 20 mmHg no less than 8 cases (89 per cent) failed to heal. The difference in failure rate is significant (P < 0.0001). Out of the 15 failed BK amputations at low pressures (below 30 mmHg) only one case had local signs of ischaemia, which might have warned the surgeons. On the other hand, in 13 out of the 18 cases of primary AK (or TK) amputations there were clinical signs of ischaemia of the calf, comprising temperature demarcation, cyanosis and/or necrotic skin lesion. The SPP below the knee appeared in all these cases to lie below 30 mmHg. In the 5 other cases of primary AK (or TK) amputation the knee was sacrificed for reasons other than signs of local ischaemia, e.g. poor physical or mental condition. It was moreover found that the presence of pulsations in the popliteal artery indicated an 89 per cent chance of healing of BK amputations. Infection was present in 24 BK amputations (28 per cent) and equally frequent among diabetic and non-diabetic cases. The postoperative SPP measured on the stumps averaged only 5 mmHg (P <0.05) higher than the preoperative SPP explaining why the preoperative SPP related closely to the postoperative course. It is concluded that ischaemia at the BK election site cannot be ruled out by clinical assessment alone and that preoperative determination of the SPP can be used in determining the chance of healing in BK amputations.     

微球囊血管扩张成形术在膝下动脉闭塞性病变中的应用

目的:总结微球囊扩张成形术治疗膝下动脉闭塞性病变技术要点。方法:采用微球囊扩张成形术治疗106例膝下动脉病变为主的重症周围动脉闭塞性疾病。结果:例患者中,截肢率为2%,死亡率为1%。7例临床未获得成功的患者中截肢率为43%,死亡率为14%。结论:介入治疗成功率93.4%。术后平均随访1年8个月,介入治疗成功的99微球囊扩张成形术治疗膝下动脉闭塞性病变成功的关键是开通经胫前、胫后和腓动脉到达足部的直接血流。     

Long-term Results of Endarterectomy, Anatomic Bypass and Extraanatomic Bypass for Aortoiliac Occlusive Disease

(Received for publication on Sept. 4, 1996; accepted on Mar. 4, 1997)     

Improvement of Microcirculatory Blood Flow under Epidural Spinal Cord Stimulation in Patients with Nonreconstructible Peripheral Arterial Occlusive Disease

Abstract: Epidural spinal cord stimulation (ESCS) has been suggested as a method to improve microcirculatory blood flow and to reduce the amputation rate in vascular patients. We studied the effects of ESCS on microcirculatory blood flow in 237 patients with nonreconstructible peripheral arterial occlusive disease. Clinical status was classified as Fontaine Stage 3 (ischemic rest pain) in 169 patients and as Fontaine Stage 4 (ulcers/gangrene) in 68 patients. After a mean follow-up period of 31.2 months, major pain relief (<75%) was noticed in patients who retained their limbs. Sixty-four patients underwent major amputation despite ESCS. Clinical improvement was confirmed by the increase in transcutaneous oxygen (TcPo₂).     

Epidemiology of Atherosclerotic Peripheral Arterial Occlusive Disease in Hong Kong

p < 0.001), age (p < 0.001), nonsmoking (p < 0.001), diabetes (p < 0.005), a low hemoglobin/hematocrit (p < 0.001), a high white blood cell count (p < 0.001), and high levels of fibrinogen (p < 0.01) and cholesterol (p < 0.05). An increasing incidence of PAD was noted in Hong Kong. Most of the patients present late with advanced ischemia. It is possible that this disease pattern represents only a fraction of the true incidence of PAD in the territory.     

Pharmacokinetics of Ropivacaine in Patients with Chronic End-stage Liver Disease

Background: Ropivacaine is mainly eliminated by hepatic metabolism. The authors studied the effect of chronic end-stage liver disease on the pharmacokinetics of ropivacaine.

Methods: Thirteen patients with chronic end-stage liver disease and eight healthy volunteers received a single dose of 0.6 mg/kg ropivacaine intravenously over 30 min. Ropivacaine, 3-hydroxyropivacaine, and 2',6'-pipecoloxylidide were measured in venous plasma and urine.

Results: Peak ropivacaine plasma concentrations were similar. Patients with chronic end-stage liver disease had, on average, 60% lower total (P = 0.001) and 56% lower unbound plasma clearance (P = 0.002), 59% higher steady state volume of distribution (P = 0.03), and 4.2-fold longer half-life (P < 0.001) of ropivacaine. Of the variation in total ropivacaine clearance, 69% was accounted for by variation in albumin, 57% in prealbumin, 25% in international normalized ratio of plasma thromboplastin time, and 24% in galactose half-life. The patients excreted a larger fraction of the original dose as unchanged ropivacaine (2.1% vs. 0.3%; P < 0.001) and a smaller fraction as 3-hydroxyropivacaine (11% vs. 27%; P = 0.001). The fraction excreted as 2',6'-pipecoloxylidide (4.7% vs. 5.0%) was similar.