Biomedical subjects

F T Padberg

Publications and source records attributed to F T Padberg.

At least 37 records · Page 2Linked to original sources

PubMed1996

Transcutaneous oxygen (TcPO2) estimates probability of healing in the ischemic extremity.

The severity of arterial ischemia is a major variable affecting healing of extremity wounds. By relating risk of failure to severity of ischemia, the probability of wound healing may be stratified along with assessment of general medical risks. Transcutaneous oxygen tension (TcPO2) arterial segmental pressure (ASP), and arterial segmental indices (ASI) were obtained in 204 ischemic lower extremity sites; 63% of the sites were in patients with diabetes mellitus (DM), 11% in patients with chronic renal failure (CRF), and 37% in patients with neither DM nor CRF (ND). Wounds included 126 amputations and 78 gangrenous ulcerations of the foot or toes. Healing (n = 112) was defined as complete wound closure, without regard to the time required. Failure (n = 92) was defined by the requirement for either arterial reconstruction (n = 45) or proximal amputation (n = 47). Stepwise multiple regression analysis was used to assess the relative contribution of each measurement and to predict the probability of healing; TcP02 was superior to ASP and ASI in all categories. TcP02 was the only test meeting the P < 0.05 entry criteria modeled by the regression. An accuracy of 83% was achieved. However, when each test was evaluated by univariate analysis, ASP and ASI did meet the criteria for the ND group. However, the accuracy was 68 and 72%, respectively. Predictive accuracy of TcP02 was unaffected by DM or CRF. ASP and ASI were satisfactory in the ND group, although of slightly reduced accuracy. ASP and ASI were misleading and inaccurate in DM and CRF. Thus, of the noninvasive tests, TcP02 alone is sufficient for objective risk stratification of arterial ischemia in the lower extremity.

Blood Gas Monitoring, Transcutaneous↗

PubMed1996

Hemodynamic and clinical improvement after superficial vein ablation in primary combined venous insufficiency with ulceration.

PURPOSE: This study was undertaken to determine the degree of clinical and hemodynamic improvement after surgical ablation of incompetent superficial and perforator veins in limbs with combined deep and superficial venous incompetence manifested by chronic dermal ulceration. METHODS: Eleven limbs in 10 patients with class 5 or 6 venous insufficiency (ulceration) were assessed by CEAP (clinical, etiologic, anatomic, pathophysiologic) clinical scores, air plethysmography, color duplex ultrasonography, and phlebography (both ascending and descending). Surgical ablation of superficial and perforating veins was performed, followed by repeat clinical, air plethysmographic, and color duplex ultrasonographic examinations. RESULTS: All 11 limbs had combined deep and superficial vein reflux on the preoperative color duplex ultrasound scan. Clinical symptom scores decreased from 10 to 1.4 after operation. Postoperative air plethysmography demonstrated significant reduction in reflux as measured by the mean venous filling index, which decreased from 12 +/- 5 ml/sec to 2.7 +/- 1 ml/sec after surgery. Calf pump function was also significantly improved, with a mean ejection fraction that increased from 43% +/- 11 to 59% +/- 13 and mean residual volume fraction that decreased from 56% +/- 15 to 33% +/- 16. Each of these measures was significantly different from the preoperative value (p < 0.05). Similar improvement characterized subgroups of limbs with three or more incompetent deep segments (n = 6) or popliteal segment incompetence (n = 6). CONCLUSIONS: Superficial and perforating vein incompetence accounts for a substantial and correctable component of venous insufficiency in limbs with combined deep and superficial vein reflux and venous ulceration. These data indicate that surgical correction of this component significantly improves clinical symptoms and venous hemodynamics. Superficial and perforator ablation is an appropriate initial step in the management of combined deep and superficial venous incompetence.

Aged↗

PubMed1996

A program of operative angioplasty: endovascular intervention and the vascular surgeon.

PURPOSE: Vascular surgeons are ideally suited to select and perform endovascular interventions either as primary therapy or as an adjunct to bypass surgery. Attaining proficiency in endovascular techniques is an important goal in the training of vascular surgeons. We report our initial experience with a program of endovascular intervention performed in the operating room by vascular surgeons. METHODS: During the previous three years, we performed 109 angioplasty procedures, 60 aortoiliac (55%), 32 femoropopliteal (29%), and 17 popliteal/tibial (16%), using guidewires and angioplasty balloons directed by intraoperative digital subtraction C-arm arteriography with road-mapping capabilities. Indications for angioplasty included disabling claudication in 59 patients (54%), rest pain in 18 (17%), and tissue loss in 32 (29%). Angioplasty was accompanied by stent placement in 39 of 60 aortoiliac procedures (65%) and in two of 32 femoral procedures (6%). In 16 cases (15%), the endovascular procedure was performed in conjunction with a bypass procedure. In selected cases (15, 14%), duplex scanning was the sole diagnostic method used before surgery to identify the lesion, eliminating the need for preoperative arteriographic scans. Segmental pressure measurements, duplex ultrasound scans, and treadmill exercise testing as indicated were performed before and after surgery. The efficacy of the endovascular intervention was assessed at 3-month intervals during the first year and at 6-month intervals thereafter. RESULTS: A successful results was defined using criteria recommended by the Ad Hoc Subcommittee on Reporting Standards for Endovascular Procedures from the Society for Vascular Surgery/International Society for Cardiovascular Surgery. This included the combination of symptomatic improvement, obtaining an anatomically successful result with < 30% residual lumen stenosis, and elimination of the translesion gradient with an improvement in high thigh-brachial index or ankle-brachial index greater than 0.15. Initial success was achieved in 55 of 60 aortoiliac (92%), 28 of 32 femoropopliteal (88%), and 16 of 17 popliteal/tibial (94%) angioplasty procedures. Clinical follow-up has been achieved in all cases, with continued clinical success rates of 80%, 75%, and 82% for aortoiliac, femoropopliteal, and popliteal/tibial angioplasty procedures, respectively, with a mean follow-up of 15.7 months. CONCLUSION: These results confirm the value of a program in which C-arm technology was used by vascular surgeons in the performance of angioplasty and stenting procedures in the operating room. This experience in therapeutic endovascular intervention will facilitate the credentialing process for future vascular surgeons.

Aged↗

PubMed1996

Survival of nosocomial pathogenic bacteria at ambient temperature.

Staphylococcus aureus and many gram-negative rods are prevalent nosocomial pathogens. The mechanisms by which these organisms persist and spread within the hospital environment have not been clearly defined. We found that these bacteria have an extraordinary capability for survival in the environment. The viabilities of staphylococcal and gram-negative (Escherichia coli and Pseudomonas aeruginosa) isolates were assessed on three environmental surfaces: a non-nutrient surface, a woven cotton fiber, and a blood protein coagulum. The bacteria were dried on these surfaces and quantitatively subcultured over six months. The viability was consistently higher on dried blood surfaces. Viability was next highest on cotton strings. For both of these environments, staphylococci appeared to lose viability between three and six months, while E. coli and P. aeruginosa survived longer. Survival on a clean non-nutrient surface (tubes alone) for all organisms was much briefer and did not extend beyond four weeks. Such extended survival on blood and fiber surfaces, as observed in part, explains the difficulty in controlling colonization of patients by and spread of these nosocomial pathogens.

Cross Infection↗

PubMed1995

Accuracy of disincorporation for identification of vascular graft infection.

OBJECTIVE: The presence or absence of prosthetic graft incorporation with surrounding tissue was assessed relative to bacterial culture results, using enhanced microbiologic culture techniques. DESIGN: Criterion standard. SETTING: University and Veterans Affairs hospital. PATIENTS: Prosthetic samples were removed from 113 aortofemoral, extra-anatomic, infrainguinal, and hemoaccess sites at the time of vascular reoperative surgery. Harvested grafts were sonicated. Density of organisms was determined by quantitative culture. MAIN OUTCOME MEASURES: The culture result was predicted from the status of prosthetic incorporation or disincorporation as determined at surgery. For purposes of this study, any bacterial growth represented graft infection. RESULTS: Cultures positive for bacteria were obtained from 31 sites; cultures with no growth, from 82. Thirty-one of the 113 sites were disincorporated, of which 23 yielded cultures positive for bacteria, and eight, no growth. The remaining 82 sites were well incorporated, of which 74 yielded cultures negative for bacteria, and eight, bacterial growth. Sixteen (14%) incorrect predictions were noted. The concurrence of disincorporation and a culture positive for bacteria relative to all culture-positive grafts (sensitivity) was 74%. The concurrence of incorporation and cultures negative for bacteria relative to all culture-negative grafts (specificity) was 90% in prostheses implanted for longer than 2 weeks; in prostheses implanted for longer than 12 weeks, specificity was 97%. CONCLUSIONS: The surgical finding of incorporation or disincorporation accurately predicted the culture result in 89% of the sites. Disincorporation correlated with presence of bacteria in 71%; incorporation reliably excluded the presence of bacteria in 97%.

Aorta↗

PubMed1995

Limited range of motion is a significant factor in venous ulceration.

PURPOSE: Calf muscle pump dysfunction is a recognized factor in chronic venous insufficiency (CVI). We investigated the hypothesis that limbs with CVI have a reduced ankle range of motion (ROM) that may be responsible for the poor calf pump function associated with venous ulceration. METHODS: Ankle ROM and calf pump function were assessed in 32 limbs of 26 adult men. Limbs were selected on the basis of clinical presentation: normal (n = 6 limbs), class 1 or 2 CVI with no history of ulceration (n = 9 limbs), class 3 CVI with healed ulceration (n = 9 limbs), and class 3 CVI with active ulceration (n = 8 limbs). ROM was determined by goniometry during maximal plantar flexion and dorsiflexion of the ankle. Calf pump function was determined by air plethysmographic measurement of ejection fraction (EF) and residual volume fraction (RVF). RESULTS: Ankle ROM was significantly (p < 0.05) reduced in each CVI group compared with age-matched control subjects, because of decreases in both plantar flexion and dorsiflexion. Calf pump function was significantly impaired (decreased EF and increased RVF) in ulcerated limbs. ROM was significantly correlated to EF and RVF. Impairment of ROM and calf pump function was associated with deterioration in the clinical classification of venous disease. CONCLUSIONS: Limbs with CVI have a limited ankle ROM that decreases with increasing severity of clinical symptoms. This decreased ROM is associated with, and may contribute to, poor calf pump function.

Aged↗

PubMed1994

The significance of calf muscle pump function in venous ulceration.

PURPOSE: Patients with clinically evident chronic venous insufficiency were evaluated to relate the degree of insufficiency and calf muscle pump dysfunction to venous ulceration. METHODS: Sixty-nine limbs in 55 patients with chronic venous insufficiency by Society for Vascular Surgery/International Society for Cardiovascular Surgery Classification were compared in three groups: classes 1 and 2 with no history of ulceration (19 limbs); class 3 with healed ulceration (20 limbs); and class 3 with active ulcers (30 limbs). Air plethysmography measurements of outflow fraction, venous volume, venous filling time, venous filling index, ejection fraction, ejection volume, residual volume fraction, and residual volume were made. In 62 of the 69 limbs, color-flow duplex ultrasonography was used to determine the pattern of reflux. RESULTS: The outflow fraction was normal in 84%, 75%, and 77% of nonulcerated, healed, and ulcerated limbs. The venous filling index was abnormal in most limbs (nonulcerated 95%, healed 90%, ulcerated 98%) but not significantly different among groups. Differences in calf muscle pump function were significant. Ulcerated limbs had significantly poorer ejection fractions (p = 0.0002) and greater residual volume fractions (p = 0.0006) than nonulcerated or healed limbs. By ultrasonography, deep and superficial vein incompetence was present in most limbs and was not statistically different among groups. Although venous insufficiency was not measurably different among groups, limbs with active venous ulcers had significantly poorer calf muscle pump function than those with healed ulcers or with no history of ulceration. CONCLUSION: Venous insufficiency is necessary but not sufficient to cause ulceration, and a deficiency of the calf muscle pump is significant to the severity of venous ulceration.

Adult↗

PubMed1993

Iatrogenic placement of a Tenckhoff catheter in the bladder of a diabetic patient after penectomy.

The placement of permanent peritoneal catheters for dialysis of patients with renal failure is safe and has been popular since its modification by Tenckhoff. The majority of complications associated with these catheters are infectious in nature, manifesting as peritonitis or insertion site skin infections. Occasionally, serious complications may occur. We report the iatrogenic placement of a Tenckhoff catheter in the bladder of a penectomized patient. Consideration to this surgically altered lower genitourinary tract may have avoided this rare complication as well as aided in the postoperative management of this patient.

Catheters, Indwelling↗

PubMed1993

Refinements in the ultrasonic detection of popliteal vein reflux.

Color-flow and duplex ultrasonography were used to determine the optimal method for documenting venous valvular reflux. Popliteal veins were examined in 10 normal limbs and 11 limbs with clinical evidence of chronic venous insufficiency (CVI). Peak reflux velocity (spectral) and duration of reflux (spectral and color) were measured with the patient in supine and standing positions, with manual and pneumatic compression applied sequentially to thigh and calf. Manual and pneumatic compression produced equivalent reflux velocity and duration. In normal limbs peak reflux velocity was always less than 22 cm/sec, with a mean reverse flow duration of 0.3 sec +/- 0.03 (SEM). In limbs with CVI, reflux velocity varied widely among protocols. Reflux duration and velocity were greater in the supine position than in the standing position for both normal limbs and limbs with CVI (p < 0.04). Duration was significantly increased for thigh versus calf compression in normal limbs (p < 0.001) but decreased in limbs with CVI (p < 0.003). Methods that used thigh compression or supine position were less capable of discriminating normal limbs from limbs with CVI. Standing calf compression provided the greatest rates of sensitivity (91%), specificity (100%), and accuracy (95%). Compared with spectral Doppler scanning, color-flow ultrasonography produced a consistently shorter reflux duration (p < 0.001). In limbs with CVI with a mean spectral duration of 2.5 sec +/- 0.2 (SEM), mean color Doppler duration was 0.7 sec shorter. Our results demonstrate that popliteal vein incompetence is identified optimally by reflux duration after standing calf compression; adequate manual compression is sufficient to identify reflux; color-flow Doppler ultrasonography may underestimate reflux duration.

Adult↗

PubMed1993

Arterial intimal flaps: a comparison of primary repair, aspirin, and endovascular excision in an experimental model.

The optimal management for traumatic arterial intimal injuries is unresolved. Three therapeutic options were compared in an experimental model employing a standard intimal flap created in 51 canine superficial femoral arteries. Group 1 (14 arteries) underwent resection with end-to-end repair. Group 2 (19 arteries) received acetylsalicylic acid (ASA) and observation only. Group 3 (21 arteries) underwent endovascular excision of the flap with angioscopic guidance. Control intimal flaps (18 arteries) were created and observed without further intervention. Patency in group 1 (primary repair) and group 2 (ASA) was 100%; the patency in both was significantly (p < 0.05) greater than in the controls, which was 67%. Patency in group 3 (endovascular excision) was 79%. Residual luminal defects were observed in only 8% of the arteries repaired primarily, but in 76% of the aspirin-treated arteries. Residual luminal defects following endovascular excision were present in 53% of the arteries remaining patent. Although resection and primary repair (group 1) provided better results than observation alone (control), addition of ASA (group 2) also sustained patency. However, a high incidence of residual intimal defects occurred, the natural history of which is unknown. While endovascular excision (group 3) may become a feasible alternative, current technology provided inferior patency with frequent residual intimal defects. These results suggest that observation alone supplemented with antiplatelet medication (ASA) may be adequate treatment, but longer follow-up is necessary for confirmation.

Angioscopy↗

PubMed1992

The arterial wall response to intimal injury in an experimental model.

Repair of occult arterial injuries is advocated to prevent thrombosis, arteriovenous fistula, and pseudoaneurysm formation. However, recent clinical series describe the healing of arterial intimal injuries and recommend nonoperative therapy. To investigate the arterial wall response to intimal injury, we created intimal flaps in 46 canine femoral arteries. The intimal flaps were imaged by arteriography, angioscopy, and intravascular ultrasound acutely, and at one and three weeks and five months post-injury. Lumen area was measured using caliper techniques (arteriography) and computerized video planimetry (angioscopy, intravascular ultrasound). Intimal and medial thickness were measured by intravascular ultrasound prior to harvest for histologic evaluation by light microscopy. Analysis of 32 patent arteries was performed after exclusion of 14 thrombosed arteries. Residual lumen area (mm2) correlated closely among the imaging modalities at one week (8.7 +/- 1.1, 7.3 +/- 2.0, 6.9 +/- 1.8), three weeks (4.2 +/- 0.9, 2.9 +/- 1.0, 2.7 +/- 0.8), and five months (5.3 +/- 0.9, 5.0 +/- 0.5, 5.0 +/- 0.9). Maximal intimal and medial thickness occurred three weeks post-injury, coincident with the maximal reduction in lumen area. Although intimal injuries can cause acute and delayed arterial thromboses, observation may be appropriate in selected cases. The evaluation of those patients chosen for nonoperative therapy should extend beyond three weeks, as this is the time of maximal arterial wall response with a continued potential for adverse clinical events.

Analysis of Variance↗

PubMed1992

Optimal method for culturing vascular prosthetic grafts.

Vascular prosthetic infection may be underrecognized when identified by standard culture techniques. Improved microbiologic methodology may enhance detection of bacteria in prosthetic graft specimens, and thus may alter clinical decisions. Quantitative culture techniques were employed to compare three methods of enhancing bacterial recovery from Dacron graft cylinders seeded with commonly encountered bacterial pathogens. Methods included: (1) ultrasonic bath treatment, (2) direct ultrasonic disruption, and (3) agitation on a Vortex mixer. Ultrasonic bath treatment released bacteria with colony counts that were consistently greater by 1 log than direct ultrasonic disruption and Vortex agitation. Direct ultrasonic disruption at high energy levels selectively killed gram-negative bacteria by as much as a 4 log decrease in viable organisms. Agitation (Vortex mixing) of the specimen produced the lowest counts among the three methods tested. These data would indicate that a 5-min ultrasonic bath treatment was the optimal method of preparation of vascular prostheses for bacterial culture.

Bacteria↗

PubMed1992

Infrapopliteal arterial injury: prompt revascularization affords optimal limb salvage.

Sixty-nine limbs with infrapopliteal arterial injuries were evaluated in 68 patients. Thirty-five (50%) cases were complicated by acute limb-threatening ischemia. Management consisted of revascularization (26 limbs), ligation (15 limbs), fasciotomy only (2 limbs), observation (18 limbs), and primary amputation (8 limbs). Penetrating injuries (n = 35) had a 33% incidence of ischemia and a reduced frequency of associated injury. One delayed amputation (3%) was required. In contrast, blunt injuries (n = 34) had a 68% incidence of ischemia and a greater frequency of associated injury. There were 20 amputations in the blunt group, including eight primary amputations performed in limbs with profound ischemia, complex open fractures, severe soft-tissue damage, and neural injury. Observation or ligation of single arterial injuries resulted in no early amputations. Associated local injuries in both groups included fracture or ligamentous disruption (64%), severe soft-tissue damage (32%), and nerve dysfunction (36%). In both groups, 15 of 35 ischemic limbs were salvaged by prompt revascularization (11 penetrating and four blunt injuries). Aggressive revascularization with autogenous repair or bypass is recommended for management of penetrating trauma. Though a good outcome will be achieved in some patients with combined blunt trauma and infrapopliteal arterial injury, the probability of delayed amputation and prolonged disability must be consciously integrated into the decision to pursue limb salvage. The prognosis for blunt injury complicated by arterial ischemia is poor; thus the severity of associated local and remote injuries will affect the results of revascularization program.

Adult↗

PubMed1992

Hemoaccess site infection.

Infectious complications involving a hemoaccess graft or fistula are a significant cause of morbidity in patients on chronic hemodialysis. A review of 274 consecutive hemoaccess procedures identified 28 infections (an incidence of 10 per cent). Infections occurred in 27 polytetrafluoroethylene (PTFE) grafts. The predominant organism was Staphylococcus aureus. Partial excision resolved 14 of the 27 graft infections. The remaining 13 required complete removal. Surgical management required six arterial ligations and seven autogenous reconstructions. No limb ischemia or mortality was directly attributable to these procedures. One infection occurred in 48 autogenous fistulas (an incidence of 2 per cent). Although partial removal of an infected prosthesis was often sufficient, brachial artery ligation was well tolerated when required to control anastomotic infection.

Adult↗

PubMed1991

Carotid endarterectomy for asymptomatic carotid stenosis: a ten-year experience with 120 procedures in a fellowship training program.

Performance of carotid endarterectomy for asymptomatic carotid stenosis has been restricted during recent years because of concern of reported complications in as high as 10-15% of patients, as well as limited long-term data on stroke protection. During the last 10 years, we have studied immediate and long-term results of carotid endarterectomy for asymptomatic disease in 120 patients. Operations were performed by a clinical vascular fellow with a staff surgeon in attendance in 113 (94%) cases with the remainder performed by the staff surgeon. Patients' mean age was 66 years; 82% were men. Risk factors included hypertension (56%), smoking (52%), coronary artery disease (32%), diabetes (24%), and hypercholesterolemia (6%). Arteriographic severity of stenoses was 80-99% in 74%, 60-79% in 22%, and 40-59% in 4% of cases. Postoperative complications included two transient neurological events (1.7%). No permanent strokes or deaths occurred. Using the life table method, cumulative stroke rate was 4.5% for ipsilateral events and 7.3% for contralateral events, confirming the high degree of stroke protection afforded by carotid endarterectomy in this population. Since these results were accomplished in a fellowship training program, we regard adequacy of this experience as the most influential factor in accomplishing this record. Surgeons who are unable to achieve comparable results should consider abandonment of the procedure or an extended period of additional training.

Aged↗

PubMed1991

A prospective evaluation of arterial intimal injuries in an experimental model.

The management of arterial intimal defects remains controversial because of uncertainty concerning their natural history. We developed an experimental canine model to prospectively evaluate posterior wall intimal flaps in the superficial femoral artery. Arterial intimal flaps were constructed in 20 anesthetized dogs (40 arteries) and evaluated by arteriography, and angioscopy, and intravascular ultrasound. Postoperative patency rates at 1 (n = 20) and 3 weeks (n = 20) were compared with a control group of ten animals (n = 20, arteriotomy without intimal flap). Acute thromboses occurred in five experimental arteries with thromboses of eight additional experimental arteries at followup. Control patency was 100%, while experimental group patencies were 75% (p less than 0.05) at 1 week and 60% (p less than 0.009) at 3 weeks. All thrombosed arteries had intimal flaps with greater than 75% luminal stenosis. We conclude that intimal injuries cause arterial thromboses acutely and during subsequent followup. Intimal flaps with stenosis greater than 75% as determined arteriographically are at greatest risk for thrombosis. Angioscopy and intravascular ultrasound characterize arterial intimal defects and may delineate injuries requiring surgical or endovascular repair.

Angiography↗

PubMed1991

Bactericidal effects of antibiotics on slowly growing and nongrowing bacteria.

Antimicrobial agents are most often tested against bacteria in the log phase of multiplication to produce the maximum bactericidal effect. In an infection, bacteria may multiply less optimally. We examined the effects of several classes of antimicrobial agents to determine their actions on gram-positive and gram-negative bacteria during nongrowing and slowly growing phases. Only ciprofloxacin and ofloxacin exhibited bactericidal activity against nongrowing gram-negative bacteria, and no antibiotics were bactericidal (3-order-of-magnitude killing) against Staphylococcus aureus. For the very slowly growing gram-negative bacteria studied, gentamicin (an aminoglycoside), imipenem (a carbapenem), meropenem (a carbapenem), ciprofloxacin (a fluoroquinolone), and ofloxacin (a fluoroquinolone) exhibited up to 5.7 orders of magnitude more killing than piperacillin or cefotaxime. This is in contrast to optimally growing bacteria, in which a wide variety of antibiotic classes produced 99.9% killing. For the gram-positive and gram-negative bacteria we examined, antibiotic killing was greatly dependent on the growth rate. The clinical implications of slow killing by chemotherapeutic agents for established bacterial infections and infections involving foreign bodies are unknown.

4-Quinolones↗

PubMed1990

Popliteal artery agenesis: a new anatomic variant.

Agenesis of the popliteal artery has not been described as a vascular anomaly in the lower extremity. This case report describes congenital absence of the popliteal artery discovered during operative exploration after a traumatic injury to the lower extremity. The preoperative arteriogram suggested acute occlusion of the popliteal artery. Intraoperative exploration and arteriography were consistent with agenesis of the popliteal arterial segment, and postmortem examination confirmed these arteriographic and intraoperative observations. Embryologically, failure of the middle portion of the sciatic artery to persist would account for this anomaly. A review of series reporting congenital anomalies of the lower extremity vasculature failed to discover previous mention of this particular abnormality. Agenesis of the popliteal artery should be included among those vascular anomalies that may affect management of lower extremity vascular disease.

Adult↗