VASCULAR SURGERY Published five times
a
year under the auspices
THE ANGIO~LOGY RESEARCH
of
FOUNDATION,
INC.
SURGICAL TREATMENT OF OCCLUSIVE ARTERIAL DISEASE OF THE LEGS PETER METZ, PHILIP SAGER
AND
ERIK HART
HANSEN, F.I.C.A.
The management of obliterative arteriosclerotic vascular disease has undergone considerable change over the past 25 years, especially in pre and postoperative assessment and operative techniques. This Department, with 110 beds mainly reserved for surgery of the extremities, serves as a receiving ward for approximately 300,000 of Copenhagen’s inhabitants in this capacity. That part of this clientel suffering from arteriosclerosis in the lower limbs will be considered in the following sections. MATERIAL AND RESULTS
10-year period (1959-68), 982 patients, out of a total admission of admitted to the Department suffering from arteriosclerotic disease of the lower limbs, with symptoms varying from intermittant
During
24,000,
a
were
claudication to marked gangrene. Conservative treatment, as described by Mathiesenl and Larsen & Lassenz2 was used alone in 425 patients. The general or local condition of a further 271 patients was so poor that, after varying periods of observation, either below knee or above knee amputation had to be performed. More recently, distal arterial blood pressure measurement has been found helpful in deciding the level for amputation3. After demonstration of the effect of a lumbar sympathetic block, judged by sympathico-galvanic reflex and skin temperature changes, 25 patients were primarily treated by lumbar sympathectomy. Eleven of these patients later
required amputation. It was considered that a vascular reconstructive operation was indicated in the remaining 261 patients. In 25 of these the operation was not carried through, either because the preliminary dissection restored normal circulation (5 cases), or because the arteriosclerotic changes appeared to be too advanced (20 cases)-in three of whom lumbar sympathectomy was undertaken instead. One of the patients died postoperatively, and amputation was necessary in four cases.
Reconstructive
operations
A total of 255 reconstructive arterial operations were completed 236 patients-19 having operations on both legs.
remaining
1
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
on
the
2 The 236 patients, 183
(37-85)
being male
and 53
female, had
an
average age of 60
years.
Half the patients had had symptoms for over two years, some for more than 10 years, and there was demonstrable arterial insufficiency in the other leg in 60% of the cases, six having been amputated previously. The majority had before their referral received more or less rational types of conservative treatment, such as vasodilators, sexual hormones, vitamins, lumbar sympathetic blockades, retraining and exercises. The main symptom was intermittent claudication in 110 cases, rest pain in 75, and gangrene in 70.
Indication for operation Before taking the decision to operate, the patients frequently were observed for a period of up to several months, in order to obtain a better assessment of their condition and its effect on their daily lives, as well as their response to conservative treatment, such as training by walking, giving up smoking etc., and the patient’s ability to cooperate. As a general principle, operation was avoided, if possible, during the first months after acute arterial occlusions’. Routine investigation included the assessment of possible diabetes, cardiac disease, or hypercholesterolaemia, whilst the assessment of the peripheral circulation included measurement of skin temperature, oscillography, venous filling time, reactive hyperaemia, and more recently, distal blood pressure and muscle blood flow measurements using xenon-1335~ 1. Following the decision to operate, angiography was performed either by the lumbar route or by Seldingers technique, in order to visualize both the site of the occlusion as well as the &dquo;run-off ’ below the knee. The final assessment of the possibilities of a reconstructive operation, against contraindications such as age, obesity, cardial or cerebral arteriosclerosis, or widespread vascular changes in the legs, was based on an individual estimation. Improved investigatory methods and broader experience, has led to an increasing number of operations on patients with severe vascular
insufficiency.
Operative method The operative techniques used did
not deviate from that commonly described in the textbooks7. 8, and the choice of type of operation was kept abreast with the developements in vascular surgery. First Dacron by-pass (deBakey prosthesis), then, for operations distal to inguinal ligament, an inverted vein graft, while Weavenite prostheses have been used for the proximal operations. Thrombendarterectomy was first carried out as an open procedure for local obstructions, but with employment of a ringstripper, the procedure is now used for longer obliterations. Lately, a revascularization of the deep femoral artery has been born in mind at operations at the femoral
artery’.
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
3
Earlier, routine oral anticoagulation treatment was used, continued for an indefinite postoperative period, but increasingly intravenously administered heparin has been used only. Heparin solution has furthermore been used for injection in the involved vessels. In connection with closure of the arteriotomies and anastomoses, Spongostan~ was often employed, temporarily, to obtain haemostasis. During the operation, and on each of the first two postoperative days, Dextran 40 (Rheomacrodex~) was given intravenously. The postoperative confinement to bed during this period was reduced from 8-10 days to about five days. Out of 255 reconstructive operations 142 by-pass and 113 thrombendarterectomies were performed. Forty-two of the endarterectomies were on either aorta or iliac arteries, the remaining 71 being distal to the inguinal ligament. In 44 of the by-pass operations, a vein graft was inserted with proximal anastomosis to the femoral artery, whilst an artificial graft was used for the remainder, 53 being single with proximal anastomosis to the femoral artery, 40 anastomosed proximally to either aorta or iliac arteries, and five bifurcation prostheses from aorta to both iliac or femoral arteries. RESULTS
There were postoperative complications in 59 (23%) cases, with wound infection and hematoma, and cardiopulmonary complications the most frequent. Six reoperations due to leakage at the arteriotomy or anastomosis were undertaken. There were 8 (3.4%) postoperative deaths, mainly caused by cardiac failure. Twenty (8%) were amputated before discharge from hospital due to inadequate results of the primary operation, but on admission 13 of these had had gangrene and seven suffered from rest pain. On discharge from the hospital 61% had pulsation distal to the operation site. This was still palpable in 44% of the survivors after 1 year, 36% after 2 years, 23% after 5 years, and in 18% after 8 years. Figure 1 shows the fate of the extremities according to time after operation. Sixty-two extremities were amputated during the follow-up period, on average, 14 months after the
primary operation. classified as &dquo;excellent&dquo; if there was both definite clinical and improvement pulsation distal to the site of operation at the follow-up examination. &dquo;Good&dquo; in those cases where distal pulsation has been present postoperatively, and at follow-up examination evident clinical improvement, but no distal pulsation was found. To &dquo;failure&dquo; were ascribed those cases without evident beneficial effect of the operation at the follow-up examination. &dquo;Not assessed&dquo; includes the unamputated cases which had not had a follow-up examination later than one year after the operation. The results of the operative treatment in relation to preoperative symptoms and arteriographic findings are given in table I, as well as the number Results
were
requiring amputations. The reconstructive operations
can
be divided into six groups,
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
according
to
4
FIG. 1. Fate of the extremities according to time after operation. (Unknown in 6 of the 255
cases).
type and site of operation,
as shown in table II, which also summarizes the duration of the follow-up period with corresponding results. Figure 2 shows the patency of the arterial grafts, as judged by distal pulsation, in five of these groups according to time after operation. Aneurysm in the reconstructed vessel occurred as a late complication in five cases, four being reoperated, while the fifth patient died from colonic cancer before reoperation could be carried out. In two patients, postoperative infection led to operative removal of the prosthesis after about six months.
DISCUSSION
The decision to attempt a reconstructive operation in cases of gangrene or pains is largely one of operability-the alternative being amputation. The decision to operate in patients with intermittant claudication is less straight forward, requiring careful assessment of the degree of restriction of the patients activity, general state of health, and considerations of the natural course of the disease 1°. We decided on a reconstructive operation in 261 (28%) out of 982 patients, a rather higher incidence than previously reported’. This was partly because the Department has received patients with well-advanced disease. In addition, in cases where amputation has been the likely alternarest
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
5 TABLE I. Results of treatment
according
to
gravity of symptoms and location of proximal arteriosclerotic lesion on the arteriogram.
we have preferred to attempt an arterial reconstruction as we feel that, in these elderly patients with their much reduced life expectancy, the prolongation of survival of the limb can postpone the likelihood of a wheelchair existence, and even a few years prolongation may suffice for the relatively brief period of life remaining to many of these patients. Another factor, enabling a broader view of the indications for operation, has been the relatively low operative mortality (3.4%), as similarly reported by others 11, 12, ls. Those patients requiring early postoperative amputation were all considered, preoperatively, as candidates for amputation. No direct comparison of results between the different operations groups is possible, as the choice of operation is decided as much by the accepted operative technique at that time as by the pathological condition. In view of this, it may be mentioned that contrary to earlier authors 1’, we had better results by thrombendarterectomy, than with by-pass operation, for reconstructions proximal to the inguinal ligament. Neither have we been able to show a longer patency rate, for the vein by-pass than for the artificial by-pass, for operations distal to the inguinal ligament&dquo;. Our over-all results being approximately the same as those of, for example, Fontaine et a1.12.
tive,
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
6 TABLE II. Results and
mean
observation time.
An assessment of the vascular function, based solely on the distal pulsation, will give the results that some cases, where the circulation is improved, are not included in the positive anatomical results. It should be especially mentioned that a revascularisation of the deep femoral artery can mean that the leg is saved, but it does not necessarily lead to a reestablishment of a palpable distal pulsation. The more recent clinical physiological measurements of muscle blood flow and distal blood pressure will afford the possibility of more accurate assessment.
The reconstructive arterial surgery in treatment of peripheral arteriosclerosis must be regarded as a local symptomatic treatment of a widespread pathological process. The patients often have symptoms of concomitant, more or less serious cerebral and myocardial arteriosclerosis, which are often the deciding factors in the postoperative course and the fate of the patient 16. SUMMARY
During the period 1959-68, a total of 982 patients were submitted to treatment for arteriosclerotic vascular lesions in the lomer limbs in Department M, Bispebjerg Hospital, Copenhagen. Conservative treatment solely was undertaken in 425 cases, while in addition 271 limbs were amputated after varying periods of conservative therapy or observation. Primary lumbar sympathectomy was undertaken in 25 patients. In the remaining 261 patients, indications were found for arterial reconstruction. In 25 cases explorative intervention only was undertaken. In the remaining 236 patients, 255 reconstructive interventions were undertaken during the period. These comprised 113 thrombendarterectomies,
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
7
FIG. 2. Patency rate by distal pulsation).
of reconstructed vessels after the life tables method.
(Patency confirmed
71 of which
were in vessels distal to the inguinal ligament, and 142 by-pass In the latter procedures, five bifurcation prostheses were introoperations. 40 duced, simple prostheses with proximal anastomosis to the aorta or the iliac arteries, and 53 synthetic prostheses and 44 venous prostheses with proximal anastomoses to the femoral artery. Eight patients (3.4%) died postoperatively, while amputation had to be resorted to in 20 (8%). On discharge, pulsation distal to the site of operation was found in 61% of the patients discharged, one year later in 44% of the survivors and five years later in 23%. A total of 62 (24%) limbs were amputated on an average of 14 months after operation.
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
8 cases could be assessed after an average of 4o/¡2 years. In 58 cases there definite clinical improvement and pulsation distal to the site of operation. In 44 cases, pulsation had been present after operation and definite clinical improvement, but no pulsation distal to the reconstructed vessel was found at the follow-up examination. In 122 cases no evident beneficial effect of operation could be demonstrated at follow-up examination. The indications for operation and the incidence of operation are discussed, and the results compared with those of previous publications. Prof. Erik Hart Hansen Ellehaj 11 Hellerup, Denmark
224
was
REFERENCES 1. 2.
3. 4.
5. 6.
7. 8. 9.
10.
11.
12.
13. 14. 15. 16.
Mathiesen, F. R.: Rational measures for patients with vascular insufficiency in the legs. (1970) Ugeskr. Læg. 132: 1916. Larsen, O. A. & Lassen, N. A.: Medical Treatment of Occlusive Arterial Disease of the Legs. (1969) Angiologica, 6: 288. Holstein, P.: Distal Blood Pressure as Guidance in Choice of Amputation Level. (1973), Scand. J. Clin. Lab. Invest., suppl. 128, 31: 245. Metz, P., Sager, P. & Hart Hansen, E.: Acute arterial occlusion in the lower limbs. (1973), Ugeskr. Læg. 135: 1629. Lassen, N. A., Lindberg, J. & Munck, O.: Measurement of Blood-Flow through skeletal Muscle by Intramuscular Injection of Xenon-133. (1964), The Lancet, 686. Nilssen, R., Dahn, I., Lassen, N. A. and Westling, H.: On the estimation of local effective perfusion pressure in patients with obliterative arterial disease by means of external compression over a Xenon-133 depot. (1967), Scand. J. Clin. Lab. Invest. suppl. 99, 19: 29. Martin, P.: Indications and techniques in arterial surgery. Livingstone, London 1963. Vogt, B.: Die rekonstruktive Gefässchirurgie. George Thieme, Stuttgart 1965. Martin, P., Frawley, J. E., Barabas, A. P. & Rosengarden, D. S.: On the surgery of arteriosclerosis of the profunda femoris artery. (1972): Surgery 71: 182. Humphries, A. W., de Wolfe, V. G., Young, J. R. & le Fevre, F. A.: Evaluation of the Natural History and the Results of Treatment in Occlusive Arteriosclerosis Involving the Lower Extremities in 1850 Patients. in: Wesolowski, S. A.: Fundamentals in Vascular Grafting. McGraw-Hill, New York 1963: 423. Siggaard-Andersen, J. & Engell, H. C.: Surgical Treatment of Arteriosclerosis of the Lower Limbs. (1965), Ugeskr. Læg. 45: 1435. Fontaine, R., Kieny, R., Gangloff, J. M., Cuny, A., Suhler, A., Gonzales, I. & Diaz, M. P.: Long-term results of restorative arterial surgery in obstructive diseases of the arteries. (1964), J. Cardiovasc. Surg. 33: 463. Holm, J., Nilsson, S. & Schersten, T.: Surgical Treatment of Peripheral Occlusive Arteriosclerosis. (1970), Acta Chir Scand 136: 375. Engell, H. C.: Reconstructive operations for obliterative arterial disease of the lower limbs. (1967), Acta Chir Scand 133: 433. Philips, C. E., De Weese, J. A. & Campeti, F. L.: Comparison of peripheral arterial grafts. (1961), Arch. Surg. 82: 38. De Weese, J. A. & Robb, C. G.: Autogenous Venous Bypass Five Years Later. (1971), Ann. : 346. Surg. 174
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
a
year under the auspices
THE ANGIO~LOGY RESEARCH
of
FOUNDATION,
INC.
SURGICAL TREATMENT OF OCCLUSIVE ARTERIAL DISEASE OF THE LEGS PETER METZ, PHILIP SAGER
AND
ERIK HART
HANSEN, F.I.C.A.
The management of obliterative arteriosclerotic vascular disease has undergone considerable change over the past 25 years, especially in pre and postoperative assessment and operative techniques. This Department, with 110 beds mainly reserved for surgery of the extremities, serves as a receiving ward for approximately 300,000 of Copenhagen’s inhabitants in this capacity. That part of this clientel suffering from arteriosclerosis in the lower limbs will be considered in the following sections. MATERIAL AND RESULTS
10-year period (1959-68), 982 patients, out of a total admission of admitted to the Department suffering from arteriosclerotic disease of the lower limbs, with symptoms varying from intermittant
During
24,000,
a
were
claudication to marked gangrene. Conservative treatment, as described by Mathiesenl and Larsen & Lassenz2 was used alone in 425 patients. The general or local condition of a further 271 patients was so poor that, after varying periods of observation, either below knee or above knee amputation had to be performed. More recently, distal arterial blood pressure measurement has been found helpful in deciding the level for amputation3. After demonstration of the effect of a lumbar sympathetic block, judged by sympathico-galvanic reflex and skin temperature changes, 25 patients were primarily treated by lumbar sympathectomy. Eleven of these patients later
required amputation. It was considered that a vascular reconstructive operation was indicated in the remaining 261 patients. In 25 of these the operation was not carried through, either because the preliminary dissection restored normal circulation (5 cases), or because the arteriosclerotic changes appeared to be too advanced (20 cases)-in three of whom lumbar sympathectomy was undertaken instead. One of the patients died postoperatively, and amputation was necessary in four cases.
Reconstructive
operations
A total of 255 reconstructive arterial operations were completed 236 patients-19 having operations on both legs.
remaining
1
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
on
the
2 The 236 patients, 183
(37-85)
being male
and 53
female, had
an
average age of 60
years.
Half the patients had had symptoms for over two years, some for more than 10 years, and there was demonstrable arterial insufficiency in the other leg in 60% of the cases, six having been amputated previously. The majority had before their referral received more or less rational types of conservative treatment, such as vasodilators, sexual hormones, vitamins, lumbar sympathetic blockades, retraining and exercises. The main symptom was intermittent claudication in 110 cases, rest pain in 75, and gangrene in 70.
Indication for operation Before taking the decision to operate, the patients frequently were observed for a period of up to several months, in order to obtain a better assessment of their condition and its effect on their daily lives, as well as their response to conservative treatment, such as training by walking, giving up smoking etc., and the patient’s ability to cooperate. As a general principle, operation was avoided, if possible, during the first months after acute arterial occlusions’. Routine investigation included the assessment of possible diabetes, cardiac disease, or hypercholesterolaemia, whilst the assessment of the peripheral circulation included measurement of skin temperature, oscillography, venous filling time, reactive hyperaemia, and more recently, distal blood pressure and muscle blood flow measurements using xenon-1335~ 1. Following the decision to operate, angiography was performed either by the lumbar route or by Seldingers technique, in order to visualize both the site of the occlusion as well as the &dquo;run-off ’ below the knee. The final assessment of the possibilities of a reconstructive operation, against contraindications such as age, obesity, cardial or cerebral arteriosclerosis, or widespread vascular changes in the legs, was based on an individual estimation. Improved investigatory methods and broader experience, has led to an increasing number of operations on patients with severe vascular
insufficiency.
Operative method The operative techniques used did
not deviate from that commonly described in the textbooks7. 8, and the choice of type of operation was kept abreast with the developements in vascular surgery. First Dacron by-pass (deBakey prosthesis), then, for operations distal to inguinal ligament, an inverted vein graft, while Weavenite prostheses have been used for the proximal operations. Thrombendarterectomy was first carried out as an open procedure for local obstructions, but with employment of a ringstripper, the procedure is now used for longer obliterations. Lately, a revascularization of the deep femoral artery has been born in mind at operations at the femoral
artery’.
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
3
Earlier, routine oral anticoagulation treatment was used, continued for an indefinite postoperative period, but increasingly intravenously administered heparin has been used only. Heparin solution has furthermore been used for injection in the involved vessels. In connection with closure of the arteriotomies and anastomoses, Spongostan~ was often employed, temporarily, to obtain haemostasis. During the operation, and on each of the first two postoperative days, Dextran 40 (Rheomacrodex~) was given intravenously. The postoperative confinement to bed during this period was reduced from 8-10 days to about five days. Out of 255 reconstructive operations 142 by-pass and 113 thrombendarterectomies were performed. Forty-two of the endarterectomies were on either aorta or iliac arteries, the remaining 71 being distal to the inguinal ligament. In 44 of the by-pass operations, a vein graft was inserted with proximal anastomosis to the femoral artery, whilst an artificial graft was used for the remainder, 53 being single with proximal anastomosis to the femoral artery, 40 anastomosed proximally to either aorta or iliac arteries, and five bifurcation prostheses from aorta to both iliac or femoral arteries. RESULTS
There were postoperative complications in 59 (23%) cases, with wound infection and hematoma, and cardiopulmonary complications the most frequent. Six reoperations due to leakage at the arteriotomy or anastomosis were undertaken. There were 8 (3.4%) postoperative deaths, mainly caused by cardiac failure. Twenty (8%) were amputated before discharge from hospital due to inadequate results of the primary operation, but on admission 13 of these had had gangrene and seven suffered from rest pain. On discharge from the hospital 61% had pulsation distal to the operation site. This was still palpable in 44% of the survivors after 1 year, 36% after 2 years, 23% after 5 years, and in 18% after 8 years. Figure 1 shows the fate of the extremities according to time after operation. Sixty-two extremities were amputated during the follow-up period, on average, 14 months after the
primary operation. classified as &dquo;excellent&dquo; if there was both definite clinical and improvement pulsation distal to the site of operation at the follow-up examination. &dquo;Good&dquo; in those cases where distal pulsation has been present postoperatively, and at follow-up examination evident clinical improvement, but no distal pulsation was found. To &dquo;failure&dquo; were ascribed those cases without evident beneficial effect of the operation at the follow-up examination. &dquo;Not assessed&dquo; includes the unamputated cases which had not had a follow-up examination later than one year after the operation. The results of the operative treatment in relation to preoperative symptoms and arteriographic findings are given in table I, as well as the number Results
were
requiring amputations. The reconstructive operations
can
be divided into six groups,
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
according
to
4
FIG. 1. Fate of the extremities according to time after operation. (Unknown in 6 of the 255
cases).
type and site of operation,
as shown in table II, which also summarizes the duration of the follow-up period with corresponding results. Figure 2 shows the patency of the arterial grafts, as judged by distal pulsation, in five of these groups according to time after operation. Aneurysm in the reconstructed vessel occurred as a late complication in five cases, four being reoperated, while the fifth patient died from colonic cancer before reoperation could be carried out. In two patients, postoperative infection led to operative removal of the prosthesis after about six months.
DISCUSSION
The decision to attempt a reconstructive operation in cases of gangrene or pains is largely one of operability-the alternative being amputation. The decision to operate in patients with intermittant claudication is less straight forward, requiring careful assessment of the degree of restriction of the patients activity, general state of health, and considerations of the natural course of the disease 1°. We decided on a reconstructive operation in 261 (28%) out of 982 patients, a rather higher incidence than previously reported’. This was partly because the Department has received patients with well-advanced disease. In addition, in cases where amputation has been the likely alternarest
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
5 TABLE I. Results of treatment
according
to
gravity of symptoms and location of proximal arteriosclerotic lesion on the arteriogram.
we have preferred to attempt an arterial reconstruction as we feel that, in these elderly patients with their much reduced life expectancy, the prolongation of survival of the limb can postpone the likelihood of a wheelchair existence, and even a few years prolongation may suffice for the relatively brief period of life remaining to many of these patients. Another factor, enabling a broader view of the indications for operation, has been the relatively low operative mortality (3.4%), as similarly reported by others 11, 12, ls. Those patients requiring early postoperative amputation were all considered, preoperatively, as candidates for amputation. No direct comparison of results between the different operations groups is possible, as the choice of operation is decided as much by the accepted operative technique at that time as by the pathological condition. In view of this, it may be mentioned that contrary to earlier authors 1’, we had better results by thrombendarterectomy, than with by-pass operation, for reconstructions proximal to the inguinal ligament. Neither have we been able to show a longer patency rate, for the vein by-pass than for the artificial by-pass, for operations distal to the inguinal ligament&dquo;. Our over-all results being approximately the same as those of, for example, Fontaine et a1.12.
tive,
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
6 TABLE II. Results and
mean
observation time.
An assessment of the vascular function, based solely on the distal pulsation, will give the results that some cases, where the circulation is improved, are not included in the positive anatomical results. It should be especially mentioned that a revascularisation of the deep femoral artery can mean that the leg is saved, but it does not necessarily lead to a reestablishment of a palpable distal pulsation. The more recent clinical physiological measurements of muscle blood flow and distal blood pressure will afford the possibility of more accurate assessment.
The reconstructive arterial surgery in treatment of peripheral arteriosclerosis must be regarded as a local symptomatic treatment of a widespread pathological process. The patients often have symptoms of concomitant, more or less serious cerebral and myocardial arteriosclerosis, which are often the deciding factors in the postoperative course and the fate of the patient 16. SUMMARY
During the period 1959-68, a total of 982 patients were submitted to treatment for arteriosclerotic vascular lesions in the lomer limbs in Department M, Bispebjerg Hospital, Copenhagen. Conservative treatment solely was undertaken in 425 cases, while in addition 271 limbs were amputated after varying periods of conservative therapy or observation. Primary lumbar sympathectomy was undertaken in 25 patients. In the remaining 261 patients, indications were found for arterial reconstruction. In 25 cases explorative intervention only was undertaken. In the remaining 236 patients, 255 reconstructive interventions were undertaken during the period. These comprised 113 thrombendarterectomies,
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
7
FIG. 2. Patency rate by distal pulsation).
of reconstructed vessels after the life tables method.
(Patency confirmed
71 of which
were in vessels distal to the inguinal ligament, and 142 by-pass In the latter procedures, five bifurcation prostheses were introoperations. 40 duced, simple prostheses with proximal anastomosis to the aorta or the iliac arteries, and 53 synthetic prostheses and 44 venous prostheses with proximal anastomoses to the femoral artery. Eight patients (3.4%) died postoperatively, while amputation had to be resorted to in 20 (8%). On discharge, pulsation distal to the site of operation was found in 61% of the patients discharged, one year later in 44% of the survivors and five years later in 23%. A total of 62 (24%) limbs were amputated on an average of 14 months after operation.
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
8 cases could be assessed after an average of 4o/¡2 years. In 58 cases there definite clinical improvement and pulsation distal to the site of operation. In 44 cases, pulsation had been present after operation and definite clinical improvement, but no pulsation distal to the reconstructed vessel was found at the follow-up examination. In 122 cases no evident beneficial effect of operation could be demonstrated at follow-up examination. The indications for operation and the incidence of operation are discussed, and the results compared with those of previous publications. Prof. Erik Hart Hansen Ellehaj 11 Hellerup, Denmark
224
was
REFERENCES 1. 2.
3. 4.
5. 6.
7. 8. 9.
10.
11.
12.
13. 14. 15. 16.
Mathiesen, F. R.: Rational measures for patients with vascular insufficiency in the legs. (1970) Ugeskr. Læg. 132: 1916. Larsen, O. A. & Lassen, N. A.: Medical Treatment of Occlusive Arterial Disease of the Legs. (1969) Angiologica, 6: 288. Holstein, P.: Distal Blood Pressure as Guidance in Choice of Amputation Level. (1973), Scand. J. Clin. Lab. Invest., suppl. 128, 31: 245. Metz, P., Sager, P. & Hart Hansen, E.: Acute arterial occlusion in the lower limbs. (1973), Ugeskr. Læg. 135: 1629. Lassen, N. A., Lindberg, J. & Munck, O.: Measurement of Blood-Flow through skeletal Muscle by Intramuscular Injection of Xenon-133. (1964), The Lancet, 686. Nilssen, R., Dahn, I., Lassen, N. A. and Westling, H.: On the estimation of local effective perfusion pressure in patients with obliterative arterial disease by means of external compression over a Xenon-133 depot. (1967), Scand. J. Clin. Lab. Invest. suppl. 99, 19: 29. Martin, P.: Indications and techniques in arterial surgery. Livingstone, London 1963. Vogt, B.: Die rekonstruktive Gefässchirurgie. George Thieme, Stuttgart 1965. Martin, P., Frawley, J. E., Barabas, A. P. & Rosengarden, D. S.: On the surgery of arteriosclerosis of the profunda femoris artery. (1972): Surgery 71: 182. Humphries, A. W., de Wolfe, V. G., Young, J. R. & le Fevre, F. A.: Evaluation of the Natural History and the Results of Treatment in Occlusive Arteriosclerosis Involving the Lower Extremities in 1850 Patients. in: Wesolowski, S. A.: Fundamentals in Vascular Grafting. McGraw-Hill, New York 1963: 423. Siggaard-Andersen, J. & Engell, H. C.: Surgical Treatment of Arteriosclerosis of the Lower Limbs. (1965), Ugeskr. Læg. 45: 1435. Fontaine, R., Kieny, R., Gangloff, J. M., Cuny, A., Suhler, A., Gonzales, I. & Diaz, M. P.: Long-term results of restorative arterial surgery in obstructive diseases of the arteries. (1964), J. Cardiovasc. Surg. 33: 463. Holm, J., Nilsson, S. & Schersten, T.: Surgical Treatment of Peripheral Occlusive Arteriosclerosis. (1970), Acta Chir Scand 136: 375. Engell, H. C.: Reconstructive operations for obliterative arterial disease of the lower limbs. (1967), Acta Chir Scand 133: 433. Philips, C. E., De Weese, J. A. & Campeti, F. L.: Comparison of peripheral arterial grafts. (1961), Arch. Surg. 82: 38. De Weese, J. A. & Robb, C. G.: Autogenous Venous Bypass Five Years Later. (1971), Ann. : 346. Surg. 174
Downloaded from ves.sagepub.com at Bobst Library, New York University on April 5, 2015
