Femoral Arteriography
in Outpatients
W. Lawrence Wilde, MD, Cambridge, Massachusetts
Cost control has become an increasingly important consideration in modern health care delivery. The purpose of this report is to demonstrate that in selected circumstances, femoral arteriography can be performed safely and efficiently in ambulatory patients. Sixty-two patients are included in this report. Their ages ranged from forty-two to seventy-eight years, with an average of sixty-two; thirty-six were male and twenty-six female. Sixty-four examinations were performed, two patients having two studies. All patients who underwent arteriography on an outpatient basis performed by myself are included. Selection of Patients The primary consideration for inclusion in the study group was evidence of ischemia confined to a leg or foot in the presence of a vigorous ipsilateral femoral pulse. If there was any doubt about the femoral pulse, if an abdominal bruit was detected, or if claudication of the hip or buttock existed, the patient was hospitalized and aortography performed. Patients with rest pain, gangrene, or cerebral deterioration were not accepted nor were patients taking anticoagulants. Technic of Arteriography The patients were not sedated and no special preparation was employed. The femoral artery was cannulated with an 18 gauge spinal needle after infiltration of the skin with Lidocainem. Care was taken to obtain a “clean stick” and in no case was the artery knowingly punctured more than once. By advancing the needle with its obturator removed, perforation of the anterior wall of the artery is detected immediately. Contrast material was injected manually with a 50 cc syringe, and suitable exposures were obtained either with a From the Department of Surgery, Boston University School of Medicine, Boston, Massachusetts. Reprint requests should be addressed to W. Lawrence Wilde, MD. 575 Mount Auburn Street, Cambridge, Massachusens 02136.
606
rapid cassette changer or with two or three individual 14 by 17 inch plates, properly timed. When adequate films had been obtained, the needle was withdrawn, the puncture site controlled with local pressure for a few minutes, and the patient moved to a stretcher and asked to lie still for ten minutes. If there was no evidence of bleeding or hematoma formation, the patient was allowed to leave. Bulky dressings were not applied. Results All patients tolerated the procedure well and no allergic reactions were noted. One patient vomited after the first injection. There were no complications in any case. By complication is meant hematoma formation, bleeding for more than a few minutes, delayed bleeding, arterial occlusion, or any other ill effect requiring treatment. No patient had to be admitted for any aftereffect of the procedure. It is of interest that this type of examination is relatively atraumatic. Repeatedly, patients who had had arteriograms taken elsewhere expressed surprise and relief at the modest discomfort they were subjected to during this arteriogram. There were two patients in whom satisfactory films were not obtained; apparently the needle had not been well placed and had become dislodged during the injection, with extravasation of dye. No attempt was made to recannulate the artery; the needle was withdrawn and the procedure terminated. Suitable arteriograms were obtained subsequently on an inpatient basis. With these two exceptions, films of satisfactory technical quality were obtained in every case. Contrast and detail were generally equal or superior to the results obtained with aortography. Examples of representative films and an illustrative case history follow. The patient (CP), a seventy-five year old man, had undergone a cephalic vein bypass graft from the right common femoral to posterior tibia1 artery on June 6, 1973 because of a thrombosed popliteal aneurysm. The saphenous veins had been removed many years before.
TheAmericanJournal
of Surgery
Femoral Arteriography
in Outpatients
Ffgure 1. Patient CP, right lower limb. Distal arteriogram demonstrating a functioning cephalic vein bypass graft anastomosed to the posterior tibia/ artery. The distal artery has become occluded; a hypertrophied collateral channel to the peroneal artery is open, but there is a stenotic area at the origin of the collateral. Figure 2. Patient CP, lefl lower limb. Proximal arteriogram demonstrating total occlusion of the superficial femoral artery. Figure 3. Distal arteriogram, left lower limb as in Figure 2. There is no suitable outffo w tract. He had had intermittent claudication of the left leg for several years and began to develop the same symptom in the right leg three months after the bypass graft was performed. Examination revealed that he continued to have a pulsating graft, but the recently established distal posterior tibia1 pulse had disappeared. A right femoral arteriogram taken on an outpatient basis revealed that the posterior tibia1 artery distal to the anastomosis of the cephalic vein graft, had become occluded; a small stenotic collateral to the peroneal artery was open. (Figure 1.) Since the foot seemed viable, the patient was ad-vised against having further surgery. One week later, because of continuing symptoms of ischemia of the left foot, a left femoral arteriogram was taken again on an outpatient basis and revealed occlusion of the left femoral and popliteal arteries, with no suitable distal outflow channel. (Figures 2 and 3.) Again, surgery was not recommended.
Comments This experience demonstrates that femoral arteriography can be performed satisfactorily in selected patients on an outpatient basis with safety. Unnecessary hospitalization is avoided in patients whose arteriograms reveal that they are not suitable candidates for vascular reconstruction. Among those hospitalized for surgery, preadmission arteriography decreases hospital stay by at least one day. The saving in cost and in medical
Volume
129,
June
1975
manpower is evident. Perhaps the greatest benefit of outpatient arteriography is that it enables the surgeon to obtain follow-up arteriograms conveniently without the need for hospital admission. A conceivable objection to this method is that a femoral arteriogram obtained through a needle is not a complete examination, as it seldom gives complete visualization of the distal aorta and iliac tree. However, in patients with strong femoral pulses, such visualization is unnecessary if the symptoms are confined to a leg or foot. Another possible objection is the fear of legal liability in case of complications in a nonhospitalized patient. As long as the patient’s informed consent is obtained and the procedure is performed carefully, the risk of legal consequences should be no different from that of any other procedure. The experience just described might lead one to expect that the risk is slight indeed. Conclusion Sixty-four femoral arteriograms were taken on an outpatient, ambulatory basis in sixty-two patients. There were no complications. It. is believed that this method, when applicable, should effect substantial savings in health delivery cost and medical manpower and should facilitate adequate follow-up examinations in certain cases.
607
in Outpatients
W. Lawrence Wilde, MD, Cambridge, Massachusetts
Cost control has become an increasingly important consideration in modern health care delivery. The purpose of this report is to demonstrate that in selected circumstances, femoral arteriography can be performed safely and efficiently in ambulatory patients. Sixty-two patients are included in this report. Their ages ranged from forty-two to seventy-eight years, with an average of sixty-two; thirty-six were male and twenty-six female. Sixty-four examinations were performed, two patients having two studies. All patients who underwent arteriography on an outpatient basis performed by myself are included. Selection of Patients The primary consideration for inclusion in the study group was evidence of ischemia confined to a leg or foot in the presence of a vigorous ipsilateral femoral pulse. If there was any doubt about the femoral pulse, if an abdominal bruit was detected, or if claudication of the hip or buttock existed, the patient was hospitalized and aortography performed. Patients with rest pain, gangrene, or cerebral deterioration were not accepted nor were patients taking anticoagulants. Technic of Arteriography The patients were not sedated and no special preparation was employed. The femoral artery was cannulated with an 18 gauge spinal needle after infiltration of the skin with Lidocainem. Care was taken to obtain a “clean stick” and in no case was the artery knowingly punctured more than once. By advancing the needle with its obturator removed, perforation of the anterior wall of the artery is detected immediately. Contrast material was injected manually with a 50 cc syringe, and suitable exposures were obtained either with a From the Department of Surgery, Boston University School of Medicine, Boston, Massachusetts. Reprint requests should be addressed to W. Lawrence Wilde, MD. 575 Mount Auburn Street, Cambridge, Massachusens 02136.
606
rapid cassette changer or with two or three individual 14 by 17 inch plates, properly timed. When adequate films had been obtained, the needle was withdrawn, the puncture site controlled with local pressure for a few minutes, and the patient moved to a stretcher and asked to lie still for ten minutes. If there was no evidence of bleeding or hematoma formation, the patient was allowed to leave. Bulky dressings were not applied. Results All patients tolerated the procedure well and no allergic reactions were noted. One patient vomited after the first injection. There were no complications in any case. By complication is meant hematoma formation, bleeding for more than a few minutes, delayed bleeding, arterial occlusion, or any other ill effect requiring treatment. No patient had to be admitted for any aftereffect of the procedure. It is of interest that this type of examination is relatively atraumatic. Repeatedly, patients who had had arteriograms taken elsewhere expressed surprise and relief at the modest discomfort they were subjected to during this arteriogram. There were two patients in whom satisfactory films were not obtained; apparently the needle had not been well placed and had become dislodged during the injection, with extravasation of dye. No attempt was made to recannulate the artery; the needle was withdrawn and the procedure terminated. Suitable arteriograms were obtained subsequently on an inpatient basis. With these two exceptions, films of satisfactory technical quality were obtained in every case. Contrast and detail were generally equal or superior to the results obtained with aortography. Examples of representative films and an illustrative case history follow. The patient (CP), a seventy-five year old man, had undergone a cephalic vein bypass graft from the right common femoral to posterior tibia1 artery on June 6, 1973 because of a thrombosed popliteal aneurysm. The saphenous veins had been removed many years before.
TheAmericanJournal
of Surgery
Femoral Arteriography
in Outpatients
Ffgure 1. Patient CP, right lower limb. Distal arteriogram demonstrating a functioning cephalic vein bypass graft anastomosed to the posterior tibia/ artery. The distal artery has become occluded; a hypertrophied collateral channel to the peroneal artery is open, but there is a stenotic area at the origin of the collateral. Figure 2. Patient CP, lefl lower limb. Proximal arteriogram demonstrating total occlusion of the superficial femoral artery. Figure 3. Distal arteriogram, left lower limb as in Figure 2. There is no suitable outffo w tract. He had had intermittent claudication of the left leg for several years and began to develop the same symptom in the right leg three months after the bypass graft was performed. Examination revealed that he continued to have a pulsating graft, but the recently established distal posterior tibia1 pulse had disappeared. A right femoral arteriogram taken on an outpatient basis revealed that the posterior tibia1 artery distal to the anastomosis of the cephalic vein graft, had become occluded; a small stenotic collateral to the peroneal artery was open. (Figure 1.) Since the foot seemed viable, the patient was ad-vised against having further surgery. One week later, because of continuing symptoms of ischemia of the left foot, a left femoral arteriogram was taken again on an outpatient basis and revealed occlusion of the left femoral and popliteal arteries, with no suitable distal outflow channel. (Figures 2 and 3.) Again, surgery was not recommended.
Comments This experience demonstrates that femoral arteriography can be performed satisfactorily in selected patients on an outpatient basis with safety. Unnecessary hospitalization is avoided in patients whose arteriograms reveal that they are not suitable candidates for vascular reconstruction. Among those hospitalized for surgery, preadmission arteriography decreases hospital stay by at least one day. The saving in cost and in medical
Volume
129,
June
1975
manpower is evident. Perhaps the greatest benefit of outpatient arteriography is that it enables the surgeon to obtain follow-up arteriograms conveniently without the need for hospital admission. A conceivable objection to this method is that a femoral arteriogram obtained through a needle is not a complete examination, as it seldom gives complete visualization of the distal aorta and iliac tree. However, in patients with strong femoral pulses, such visualization is unnecessary if the symptoms are confined to a leg or foot. Another possible objection is the fear of legal liability in case of complications in a nonhospitalized patient. As long as the patient’s informed consent is obtained and the procedure is performed carefully, the risk of legal consequences should be no different from that of any other procedure. The experience just described might lead one to expect that the risk is slight indeed. Conclusion Sixty-four femoral arteriograms were taken on an outpatient, ambulatory basis in sixty-two patients. There were no complications. It. is believed that this method, when applicable, should effect substantial savings in health delivery cost and medical manpower and should facilitate adequate follow-up examinations in certain cases.
607
