Arterial lesions of the foot vessels in diabetic and non-diabetic patients undergoing lower limb revascularisation

This study was undertaken to compare the atherosclerotic involvement of the foot arteries in diabetic and non-diabetic patients with leg ischaemia. Ninety-four non-diabetic and 57 diabetic patients were investigated with intraoperative postreconstruction serial angiography during femoro-popliteal and femoro-distal bypass surgery. The foot vessels were evaluated with regard to the anterior and posterior foot arches which were classified as intact, deficient or occluded. Integrity of the pedal circulation was defined as patency of both the anterior and posterior foot arches. Severe involvement of the foot arches was rarely seen in limbs with 3- or 2-lower leg vessel run-off to the foot. The posterior foot arch was more often spared than the anterior foot arch, especially in the non-diabetic group (P less than 0.001). The integrity of the pedal circulation was similar in diabetic and non-diabetic patients (intact in about 20%). Patients with claudication showed a significantly lower occlusion rate of leg and foot arteries than patients with rest pain or gangrene. The results of this study showed that the foot vessels were similarly affected in diabetics and non-diabetics undergoing lower limb revascularization. The same aggressive diagnostic and therapeutic approach should be applied for limb salvage in both groups.     

Assessment of the distal lower limb arteries: a comparison of arteriography and Doppler ultrasound.

Simple Doppler was compared with routine arteriography in assessing patency of the arteries at the ankle and the pedal arch. Fifty-six limbs were evaluated--29 with rest pain or trophic lesions, 20 with claudication, and 7 without symptoms. On Doppler examination 177 of 220 (80%) vessels were assessed patent, compared with 127 of 220 (58%) on arteriography. Of the 49 judged occluded on arteriograms, 59% were patent by Doppler and of 44 in which arteriograms were inadequate 82% had Doppler signals. Doppler signals could be heard in 20 of 177 (11%) vessels only with the feet dependant. This prospective, double-blind study provides numerical data to support the observation that a simple Doppler probe can detect patent distal vessels which may not be demonstrated by routine arteriography. This allows selection of patients for further more detailed arteriograms or for operative exploration with a view to distal bypass grafting.     

A modified technique of pre-operative aortography to demonstrate the complete arterial tree of the lower limb

One hundred consecutive aortograms were studied to establish the efficacy of conventional arteriography in demonstrating distal vessels and the pedal arch. The standard technique was modified by using a long injection time, a large volume of contrast material (iopamidol 370), prolonged filming and multiple exposures of the feet. On the basis of these examinations each limb was classified as having aorto-iliac disease (18 limbs), superficial femoral disease (103 limbs), combined segment disease (28 limbs) or generalised disease (51 limbs). Calf and ankle arteries were seen in 196 of the 200 limbs (98%). Patency of the pedal arch was established in 184 (92%). Fourteen percent of the group of patients with combined segment disease did not have their pedal arch visualised and this group contained most of the examination failures. This modified method of aortography can demonstrate the entire arterial tree from the aorta to the foot in 92% of limbs with symptomatic chronic atherosclerotic disease. This allows the majority of peripheral vascular reconstructions to be planned and performed without the need for intra-operative arteriography.     

Results of in-situ saphenous vein bypass to the foot

To determine the efficacy of extending vascular reconstruction to the pedal vessels, the records of 115 in-situ saphenous vein bypasses to the infragenicular vessels were examined. Ninety-four percent were performed for limb-threatening ischemia and 6 percent for claudication. Ninety-one bypasses were to tibial vessels in the calf (Group 1), whereas severe disease of the tibial vessels in the calf necessitated bypass to arteries at the ankle and beyond in 24 (Group 2). Life-table analysis was used to calculate limb salvage, graft patency, and functional status for Group 1 and Group 2 36 months postoperatively; there were no statistical differences between groups with regard to these variables (p = 0.38). Diabetes had no impact on the success of reconstruction, and preoperative noninvasive testing was not predictive of graft failure in either group. Significantly, limb salvage closely paralleled graft patency and functional status, illustrating the severe disease in all patients. Patients with severe tibial-peroneal atherosclerosis may benefit from bypass grafting to the pedal arteries with a success rate equal to those done to more proximal sites.     

The effect of distal arterial anatomy on the success of popliteal aneurysm repair

The success of bypass grafting for popliteal aneurysms may be compromised by the natural history of these lesions. During a 9-year period 35 patients had repair of 48 popliteal aneurysms. Elective repair was performed in 26 limbs and the remaining 22 limbs required urgent or emergent treatment after aneurysm thrombosis (16) or embolic digital ischemia (six). Retrospective review of preoperative and intraoperative arteriograms and CT or ultrasound scans was done to define the relationship of distal runoff anatomy to initial symptoms and long-term grafting success during a mean follow-up of 48 months. Only five of 48 limbs (10%) had three continuous tibial vessels and a patent pedal arch. Twenty-six limbs (55%) had one or no named calf vessels and 11 limbs had incomplete pedal arches. When thrombosis or symptomatic embolism occurred, the anatomy was significantly worse; 15 of 22 such limbs (68%) had one or no patent tibial vessels and seven had incomplete pedal arches. Nineteen of 28 aneurysms examined by CT or ultrasound scanning showed intraluminal thrombus. Eight of 13 patent aneurysms with intraluminal thrombus had one or no patent tibial vessels. The 5-year graft patency rate was 74% for the entire study group. Bypass for repair of asymptomatic aneurysms had a patency rate of 91% at 5 years vs 54% for symptomatic patients (p less than 0.05). Patients with popliteal aneurysms often have advanced tibial disease that appears worse in those with symptoms. The occurrence of a patent popliteal aneurysm with intraluminal thrombus and advanced runoff disease suggests that chronic microembolism may be an etiologic factor in the tibial disease observed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Symptomatology and anatomic patterns of peripheral vascular disease: Differing impact of smoking and diabetes

We retrospectively examined the impact of smoking and diabetes on the clinical presentation and arteriographic pattern of occlusion in 227 patients evaluated for symptomatic infrainguinal arterial disease. The age at which significant symptomatology developed did not differ for diabetics and nondiabetics. Diabetics had significantly more occlusion in the large arteries of the calf, however, particularly in the peroneal and posterior tibial arteries. Despite this, the extent of occlusive disease in the pedal arch was not influenced by diabetes. Diabetics also tended to present more frequently with gangrene or ulcer (greater than 70%) when compared to nondiabetic smokers (41%, p less than .01). Smokers presented with symptomatic disease earlier than nonsmokers (p less than .0005). Intermittent claudication was strongly associated with smoking; among 33 patients with claudication, 32 were smokers. In contrast to the effect of diabetes, smokers appeared to have less extensive occlusive disease in the large arteries of the calf than nonsmokers. Nondiabetic nonsmokers constituted less than 10% of our study population and presented at a significantly older age. Nevertheless, despite the absence of either risk factor, this group also tended to present with gangrene or ulcer relatively frequently (71%). Although diabetes and smoking are both risk factors for atherosclerotic disease, we conclude that their impact on the angiographic pattern of occlusion and clinical presentation differs substantially.     

Microtibial embolectomy.

BACKGROUND: microtibial embolectomy is an important technique in cases of limb threatening acute arterial occlusion affecting native crural and pedal vessels. It is particularly useful when thrombolysis is contraindicated or ineffective as in "trash foot". METHODS: in order to evaluate the efficacy of this technique, a retrospective case note review was carried out for patients undergoing microtibial embolectomy from 1990 to 1999. Data collected included the causes and degree of ischaemia, additional procedures required, vessel patency, limb salvage and complications encountered. RESULTS: twenty-two limbs underwent exploration of the crural/pedal vessels with ankle level arteriotomies under local anaesthetic in 12 cases, general anaesthetic in nine and epidural in one. The causes of ischaemia were cardiac emboli (8), "trash foot" (7), emboli from aortic and popliteal aneurysms (3) and thrombotic occlusion of crural vessels (4). The vessel patency rate was 69% and limb salvage rate 62% (13/21) up to 5-years follow-up. Six of the seven cases with "trash foot" were salvaged while one required an amputation at 3-months post-operatively. The 30-day mortality was 22% (5/22). CONCLUSIONS: microtibial embolectomy is effective in acute occlusion of the crural/pedal arteries including cases of "trash foot", offering limb salvage to a worthwhile proportion of cases.     

Risk factors for poor collateral development in claudication

The objective of this retrospective, cross-sectional study was to determine risk factors for poor collateral development in patients with claudication. The authors listed all patients with calf claudication who had undergone angiography in this hospital between 1999 and 2001 and extracted those with superficial femoral artery (SFA) occlusion, a popliteal artery without major lesions, and at least 1 patent calf artery. Forty-five patients met the criteria, and concomitant disease and claudication characteristics, ankle/brachial index (ABI) and number of outflow vessels were recorded. Three blinded observers calculated the number of collaterals on the angiograms, and the collateral count was related to the other factors by use of regression analysis. The mean patient age was 69 years (SD 11), and 62% were women. Their walking distance was 90 m (77) and ABI 0.47 (0.15). Thirty-three percent had diabetes and 50% had duration of symptoms longer than 5 years. The mean number of collaterals bypassing the occlusion was 15.1 (SD 4.8). Univariate regression analysis indicated an association (p <0.08) between few collateral vessels and diabetes, short duration of symptoms, current smoking habits, and old age. In the multivariate analysis only diabetes and short duration of symptoms were related to having few collaterals. In patients with claudication and SFA occlusion, few collaterals from the deep femoral artery appear to be associated with having diabetes and a short duration of symptoms.     

Interobserver variation in interpretation of arteriography and management of severe lower leg arterial disease.

OBJECTIVE: arteriography is the reference standard for the assessment of the lower leg arteries in patients with severe lower limb ischaemia. Interobserver variation in arteriography interpretation may cause disparities with non-invasive imaging modalities. We determined interobserver variation in lower leg artery assessment with intra-arterial digital subtraction angiography (IaDSA) and subsequent patient management. MATERIALS: iaDSA studies of patients evaluated for severe claudication (n =5) or critical ischaemia ( n =43). METHODS: arteriograms were independently judged by four observers. The popliteal and tibial arteries were graded as fully patent, severely diseased, occluded or non-diagnostic. The dorsalis pedis, common and deep plantar artery were graded as directly, indirectly or not filling the pedal arch or non-diagnostic. Agreement on grading arteries was expressed as kappa-values. Treatment plans (conservative, PTA, surgery, amputation, non-diagnostic) proposed by each observer based on clinical information and iaDSA were compared. RESULTS: the rate of non-diagnostic judgements ranged from 1% in the popliteal to 22% in the pedal arteries. Overall agreement was good for grading the popliteal arteries (kappa=0.64), moderate for the tibial (kappa=0.47--0.54) and fair for the pedal arteries (kappa=0.39). Agreement was good to excellent for grading occluded or fully patent popliteal and tibial artery segments, and fair to moderate for grading severe disease. In 57% of cases at least 3 observers proposed identical treatment, which indicates fair overall agreement (kappa=0.33). CONCLUSION: interobserver agreement on iaDSA is good to determine occluded or fully patent popliteal or tibial arteries, but not for severe disease. This should be taken into account when other diagnostic modalities are compared with iaDSA. Evaluation of diagnostic modalities as concordance in treatment plans is flawed by interindividual variation.     

Hemodynamic studies before and after extended bypass grafts to the tibial and personeal arteries.

Thirty-ones limbs of 29 consecutive patients undergoing bypass grafts to the tibial or peroneal arteries were studied. Twenty-five limbs had ischemic rest pain with or without localized gangrene, and six had incapacitating claudication. The mean segmental pressure indices were upper thigh, 1.16 +/- 0.36; above knee, 0.71 +/- 0.30; below knee 0.51 +/- 0.23; and ankle, 0.28 +/- 0.21. Indices at the ankle were significantly lower (P less than 0.005) than those obtained from limbs that were candidates for simple femoropopliteal bypass. Three grafts failed immediately (initial patency rate of 90%). In the surviving grafts, ankle pressures rose from 39 +/- 26 to 145 +/- 29 mm Hg, and the ankle pressure index increased from 0.27 +/- 0.20 to 1.03 +/- 0.15 mm Hg. Consistent with these hemodynamic changes, all patients but one initially were relieved of their symptoms, and all ischemic lesions were treated successfully. Thirteen grafts failed subsequently (21 days to 34 months). Compared with preoperative values, ankle pressures after failure were either increased or unchanged in 75% of these limbs. Early occlusion could not be predicted on the basis of a low preoperative pressure index. During follow-up, impending graft failure was detected by a fall in ankle pressure in three patients and successfully prevented.     

Popliteal artery puncture in the assessment of patients with severe leg ischemia.

Two-plane angiography and direct segmental pressure measurements in the femoral and popliteal arteries and indirectly on the arm and ankle were performed in 101 limbs seeking to establish a relationship between angiographic assessment of the patency of the popliteal artery and the trifurcation vessels and the popliteal ankle pressure difference. When the tiberoperoneal trunk or the trifurcation vessels were occluded or more than 50% of the lumen was stenosed, the pressure difference exceeded 10 mmHg in 30/40 limbs (75%). When three, two, or only one of the tibial vessels were patent, the pressure difference exceeded 10 mmHg in 2/58 limbs (3%). One month following above knee femoropopliteal bypass (48 limbs), patients with a popliteal-ankle difference less than 10 mmHg obtained a significantly higher ankle pressure index (PI 0.86, range 0.56-1.20) (p less than 0.01) than those with a pressure difference exceeding 10 mmHg (PI 0.66, range 0.40-0.91). The clinical state 6 months following femoropopliteal bypass did not demonstrate that patients with a low popliteal-ankle difference fared better than patients with a higher pressure difference; however, the PI appeared significantly lower in the latter group compared to the former. The graft material was correlated to the popliteal-ankle pressure difference. It appeared that prosthetic grafts failed within 6 months when the difference exceeded 10 mmHg in 10/12 limbs (83%), but autologous vein grafts only failed in 2/10 limbs (20%). Finally, it was possible to predict the postoperative ankle pressure index significantly from data derived from the pressure measurements.     

The "isolated" popliteal segment: a comparative evaluation of its vascular resistance

During femoro-popliteal and femoro-distal bypass, measurement of vascular resistance (VR) at the site of graft outflow may be used to quantify "run off". Intra-operative measurements were made in 51 lower limbs to compare VR in different categories of outflow; the "isolated" popliteal segment (IPS group, n = 11), the popliteal artery in continuity with patent vessels to the pedal arch (PIC group, n = 26) and the single calf vessel (SCV group, n = 14). VR was measured both before and after intra-arterial papaverine. The values in the 37 popliteal arteries were correlated with two different methods of arteriographic scoring. Vascular resistance in the IPS group (median 1149 mPRU, P = 0.003) but not significantly different from VR in the SCV group (median 1014 mPRU, range 743-1541 mPRU). VR in the SCV group was significantly greater than that in the PIC group (P = 0.006). After papaverine administration, the same relationships were observed between the IPS, PIC and SCV groups. Both before and after papaverine, VR in the popliteal artery correlated significantly with both arteriographic scores. In terms of VR, the isolated popliteal segment provides an outflow comparable to that of a single calf artery but less favourable than a popliteal artery wtih patent run off.     

Enhancing foot skin blood flux in peripheral vascular disease using intermittent pneumatic compression: controlled study on claudicants and grafted arteriopaths

Intermittent pneumatic leg compression (IPC) increases arterial calf inflow and foot skin blood flux in normal subjects and claudicants. Our hypothesis was that IPC could enhance foot skin blood flux after infrainguinal grafting and thus promote distal perfusion in limbs with tissue loss. The aim of this study was to compare the effects of three IPC modes [applied to the foot (IPCfoot), the calf (IPCcalf), or both (IPCfoot+calf)] on foot skin perfusion in healthy individuals, claudicants, and patients after infrainguinal arterial revascularization performed for critical or subcritical limb ischemia. Altogether, 20 healthy limbs, 22 claudicating limbs, and 36 limbs of arteriopaths with prior successful autologous femoropopliteal and femorodistal (18 each) grafts were examined. Five-minute laser Doppler recordings were obtained from the pulp of the big toe in the sitting position, at rest, and during random applications of IPCfoot, IPCcalf, and IPCfoot+calf delivered at 120 mmHg for 4 seconds three times per minute. Foot skin blood flux increased using all IPC modes (p <0.001), with IPCfoot and IPCfoot+calf generating higher flux levels than IPCcalf (p <0.01) in all groups. Intergroup differences of flux with each of the three IPC modes were not significant. IPCfoot and IPCfoot+calf similarly (p > 0.14) produced a higher percentage flux increase than IPCcalf in all groups (p <0.004). Controls had a higher percentage flux increase with both IPCcalf and IPCfoot than did claudicants (p ≤ 0.016). No differences were documented between normal and grafted limbs (p > 0.05). The percentage flux increase with IPCfoot+calf and IPCcalf was significantly higher in femorodistal grafts than in femoropopliteal ones (p ≤ 0.026). IPC enhances skin blood flux in limbs with infrainguinal bypass, claudication, and normal arteries, with IPCfoot and IPCfoot+calf being more effective than IPCcalf. Our findings suggest that IPC may be beneficial in limbs with impaired distal perfusion and thus may have clinical implications in the treatment of leg ulcers either prior to or after revascularization.     

Aortoiliac reconstruction in patients with combined iliac and superficial femoral arterial occlusion

Despite revascularization of the common femoral--profunda femoris system, many patients fail to obtain satisfactory relief from claudication or rest pain. Clinical observations were compared with objective physiological data in 54 technically successful aortoiliofemoral reconstructions for multilevel disease. Nine of 28 operations (32%) for claudication and five of 26 operations (19%) for ischemia at rest had poor results. While the average ankle pressure index (API = ankle blood pressure/arm blood pressure) rose from 0.52 +/- 0.03 (SEM) to 0.81 +/- 0.03 in limbs treated successfully for claudication, it changed insignificantly in those with an unsuccessful result (0.58 +/- 0.04 to 0.61 +/- 0.04). When ischemic symptoms were relieved, API rose from 0.23 +/- 0.04 to 0.55 +/- 0.03 but increased only from 0.22 +/- 0.09 to 0.40 +/- 0.02 in limbs with insufficient improvement. Preoperative thigh pressure index (TPI) in claudicating limbs with poor results (0.96 +/- 0.05) differed little from that in limbs with good results (0.92 +/- 0.05); nor was the TPI of ischemic limbs with poor results (0.83 +/- 0.13) significantly greater than that in limbs with good results (0.60 +/- 0.05). Neither the TPI nor the thigh to ankle pressure gradient was of value in predicting which extremities would respond poorly to aortoiliofemoral reconstruction.     

Non-invasive estimation of peripheral resistance using Pulse Generated Runoff before femorodistal bypass

The measurement of peripheral resistance (PR) is a useful technique for predicting the outcome of femorodistal bypass. In an attempt, noninvasively, to predict PR, Pulse Generated Runoff (PGR) was used to assess 35 consecutive patients undergoing femorodistal non-reversed vein bypass for critical ischaemia. The PGR subscores (anterior tibial, posterior tibial, peroneal, pedal arch status were correlated against the measured PR. Using multiple linear regression three resistance values were derived for runoff at different levels: (1) a single calf vessel (R1); (2) distal popliteal artery (R3); (3) irrespective of the level (R0). There was good agreement between the predicted resistances R0, R1 and R3 and the measured PR. In the single calf vessel group (R1) the limits of agreement (-0.41 to +0.39) and 95 per cent confidence interval (-0.16 to +0.14) with the measured PR were better than in the R0 and R3 groups. These levels of agreement are small enough to replace the measured PR with the predicted PR method. Using the appropriate resistance equation in a further prospective series of 14 cases, there was agreement between the predicted and measured PR (limits of agreement -0.67 to +0.41; 95 per cent confidence interval -0.26 to +0.15). These results confirm the value of PGR in the assessment of critically ischaemic limbs particularly with a single calf vessel. Calf vessel continuity with the pedal arch appears to be a major determinant of PR, particularly in the isolated calf vessel group. A non-invasive resistance value can be derived which will predict the intraoperative peripheral resistance and should help predict subsequent graft outcome.     

Outcome of the first 100 femoropopliteal angioplasties performed in the operating theatre.

OBJECTIVES: To examine the factors influencing outcome and restenosis in an initial series of 100 infrainguinal angioplasties. DESIGN: Prospective study of angioplasties of the superficial femoral and popliteal arteries performed over a 42-month period. MATERIALS AND METHODS: One hundred consecutive angioplasties in 96 patients performed in the operating theatre between January 1993 and June 1996 were followed prospectively with clinical, ABI, and duplex assessment. Forty-four procedures were for disabling claudication and 56 for critical ischaemia. Stents were deployed in 30 limbs. RESULTS: Angioplasty was successful in 84 of 100 limbs. Cumulative patency of the entire group at 3, 6, 12 and 18 months was 78%, 60%, 53%, and 49% respectively, while excluding initial failures, gave patencies of 95%, 69%, 63%, and 58%, respectively. Claudicants with a 1-year patency of 64% did significantly better than patients with critical ischaemia (44% p < 0.05). Angioplasties performed during the initial 21 months had a 1-year patency of 42%, while those performed in the final 21 months had a 74% patency (p = N.S.). The patency for stented arteries was 66% vs. 49% for angioplasty alone (p = N.S.). The 2-year limb salvage rate was 91% in patents with critical ischaemia. Forty-six per cent of restenoses were asymptomatic. CONCLUSIONS: The results suggest that while angioplasty is useful in treating infrainguinal arterial disease, there is a learning curve, resulting in a high restenosis rate for occlusive and multilevel disease, while concomitant placement of stents may be beneficial.     

Arteriogram scoring systems and Pulse Generated Run-off in the assessment of patients with critical ischaemia for femorodistal bypass

Conventional arteriography is the investigation of choice in patients with critical ischaemia to select the site for the distal anastomosis of a femorodistal bypass. Several arteriographic scoring systems have been devised in an attempt to quantify the run-off. More recently Pulse Generated Run-off and intraoperative peripheral resistance measurements have been proposed as better predictors of early graft patency. Eighty-eight consecutive femorodistal bypass grafts were studied using Pulse Generated Run-off (PGR), conventional and intra-arterial digital subtraction arteriography (DSA) and peripheral resistance measurement. Three widely used arteriographic scoring systems were used to grade the arteriographic run-off. There were significant correlations between the scoring systems and the measured peripheral resistance, although PGR correlated better with peripheral resistance than arteriography (rs = -0.59, P less than 0.001). Intra-arterial DSA improved the correlation between the arteriogram scoring systems and the measured peripheral resistance in the distal popliteal artery, but not in single calf vessels. In contrast, PGR correlated much better with peripheral resistance in single calf vessels (rs = -0.82, P less than 0.001). We recommend that selection for femorodistal reconstruction be based on a combination of intra-arterial DSA and PGR. PGR will identify patent distal calf vessels not seen on arteriography and determine their continuity with the pedal arch, two features which are essential prerequisites for successful femorodistal bypass.     

Pedal Bypass for Limb Salvage

Background: Pedal bypass grafting is often the only method of limb salvage in patients with chronic critical lower limb ischemia due to atherosclerotic obliteration of the crural arteries, including patients with diabetic foot gangrene. It involves arterial reconstruction with distal anastomosis to one of the pedal arteries.

Material and Methods: Between January 2000 and June 2004, 54 pedal bypasses were performed in 53 patients with chronic critical lower limb ischemia. Forty-seven (87%) patients had gangrene or ischemic ulcer, 36 (68%) had diabetes. In some of the patients (16.7%), previous percutaneous transluminal angioplasty (PTA) of the crural arteries had failed. Preoperative angiographic findings were unsatisfactory in the majority of the patients; the plantar arch was not visualized in 36 (66.7%) limbs.

Results: In the period investigated (54 months) 11 grafts (20.4%) failed. Early thrombectomy resulting in long-term graft patency salvaged five limbs. One limb with graft occlusion occurring after foot ulcer healing was also salvaged. However, one amputation had to be performed despite a patent graft. The perioperative mortality rate was 3.8%. Cumulative primary and secondary graft patency rates and limb-salvage rates at 54 months were 76%, 78% and 81%, respectively.

Conclusion: Pedal bypass grafting is a safe method with very good long-term outcomes. The absence of the pedal arteries or plantar arch on preoperative angiograms need not be taken as a contraindication to pedal vascular reconstruction. In discussions on the plantar arch it is recommended to discriminate between its actual absence and a mere “angiographic” absence.     

Late complications after femoral artery catheterization in children less than five years of age

Fifty-eight children who underwent diagnostic femoral artery catheterization before 5 years of age, from 5 to 14 years before the study, were randomly selected from approximately 300 surviving patients undergoing diagnostic femoral artery catheterization at our institution during the interval. Each patient underwent vascular laboratory segmental pressure and waveform examination and arterial duplex scanning, as well as lower extremity bone length radiographs, which were considered positive if the catheterized leg was greater than or equal to 1.5 cm shorter than the opposite leg. Thirteen children who had only venous catheterization served as controls. No arterial abnormalities were present in the control patients (mean ankle/brachial index, 1.01). Arterial occlusion was present in both limbs of five patients who had bilateral diagnostic femoral artery catheterization and in 14 limbs of 51 patients who had unilateral diagnostic femoral artery catheterization. Thus arterial occlusion was present in 33% of patients (19 of 58) and in 37% of limbs (24 of 65). The mean ankle/brachial index in the catheterized limbs was 0.79. Leg growth retardation was present in four limbs (8%) of 51 children undergoing unilateral diagnostic femoral artery catheterization and in one (8%) control patient. The inverse relationship between ankle/brachial index and leg growth retardation was significant (R = 0.47, p less than 0.0005). Only one patient had symptoms of arterial occlusion (claudication), and one patient had symptoms of leg growth retardation (gait disturbance). We conclude that arterial occlusion is common after diagnostic femoral artery catheterization in children less than 5 years of age, but that excellent collateral supply prevents leg growth retardation and/or symptomatic arterial insufficiency in most children.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparative evaluation of three ambulatory plethysmographic devices as regards accuracy and handling in daily practice

We compared a computed strain gauge plethysmograph (SGP1) with a Gutmann strain gauge plethysmograph (SGP2) and a photoplethysmograph (PPG) in 24 normal and 12 radiologically proven postphlebitic limbs with respect to assessment of the calf pump function, discrimination between normal and pathologic values, and handling. Recovery time (RT50), refilling volume (RV) and the Index (RT50xRV) were measured at the ankle and the calf in each limb after 20 dorsiflexions of the feet in the sitting position. The PPG device could only measure RT50. There was a strong positive correlation in RT50, RV and Index values between SGP1 and SGP2 at the ankle and at the calf (p less than 0.001), but none in RT50 ankle and calf values between PPG and SGP1 (p = 0.1) and PPG and SGP2 (p = 0.1). The comparison between normal and postphlebitic limbs revealed significant differences for all three values RT50, RV and Index only for SGP1 ankle measurements (p less than 0.02, p less than 0.01, respectively). Ankle RT50 values were significantly longer than calf RT50 values for both strain gauge devices (p less than 0.01), where PPG results were not influenced by the site of measurement. The average number of tests required to obtain a valid curve in each limb at the ankle and calf was lowest for SGP1 measurements. Vein calf pump function is easily and accurately assessed by SGP1 ankle measurements. However a threshold limit between normal and pathologic values can not be defined either for RT50 or for RV values in the individual case, and the creation of an Index adds little to solve this problem.