Biomedical subjects
Publications and source records attributed to G J Collins.
This case illustrates an unusual application of axillofemoral bypass grafting in a patient with a pelvic ectopic kidney. Application of this technique resulted in complete relief of the patient's symptoms of intermittent claudication and allowed us to avoid a larger procedure which might have jeopardized the survival of the ectopic kidney and which would have resulted in increased morbidity for the patient.
A case of peripheral embolization from an axillary aneurysm is presented. This was successfully treated by thromboembolectomy, ligation of the axillary artery distal to the aneurysm and an axillo-axillary bypass graft. The patient has resumed full activity and his normal upper extremity pulses and pressures.
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Limb salvage procedures were performed in ninety patients during the period from 1965 to 1975. Sixteen different procedures were performed with an associated complication rate of 8.9 per cent and a mortality rate of 8.9 per cent. The patency rates were 79.7 per cent at thirty days and 72.9 per cent at last follow-up.
Patients at high risk of having thromboses can be identified not only on the basis of clinical criteria but also on the basis of laboratory studies. With use of a condensed coagulation profile consisting of six laboratory tests, the clinical impression of hypercoagulability can be confirmed in approximately 90 per cent of cases. Therapy directed to correct specific laboratory abnormalities may be more efficacious than nonspecific therapy.
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Popliteal vascular trauma continues to be associated with a relatively high morbidity rate when compared to other major vascular injuries in extremities. There is continuing controversy regarding the management of popliteal venous injuries. The advocates of ligation of injured veins have postulated that there is an increased incidence in thrombophlebitis and pulmonary embolism associated with attempted venous repair. There is a paucity of valid statistics supporting either side of this controversy. Clinical experience documented in the Vietnam Vascular Registry and experimental work at Walter Reed Army Institute of Research have supported our more aggressive approach for venous repair. This study evaluates the management of 110 injured popliteal veins without associated popliteal arterial trauma. Nearly an equal number were ligated and repaired. Thrombophlebitis and pulmonary embolism were not significant complications in this series. The only pulmonary embolus occurred after ligation of an injured popliteal vein. However, there was a significant increase in edema of the involved extremity following ligation, 50.9% compared to 13.2% after repair.
"B" mode ultrasound scanning is useful in the diagnosis of popliteal arterial aneurysms. It offers advantages over physical examination and arteriography, since these aneurysms are sometimes difficult to palpate and may be partially filled with laminated clot. The technique is noninvasive and without known hazard in this location. "B" mode ultrasound scanning promises to be useful in the diagnosis of aneurysms of other extremity arteries. It has already been useful in confirming the presence of femoral false aneurysms. Greater familiarity with the technique and improvepd technology will result in even greater reliance on ultrasound diagnosis.
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Elective vascular reconstruction was performed to correct 135 vascular lesions at Walter Reed Army Medical Center in patients who had sustained earlier vascular trauma. This represents approximately 7 per cent of the operations performed from 1967 to 1974. Approximately three fourths of the lesions resulted from combat wounds and the remaining one fourth from civilian trauma. Of the 135 lesions, fifty-two were arteriovenous fistulas, thirty-five were false aneurysms, and the remaining forty-eight lesions involved thrombosis or stenosis. The popliteal artery was involved most frequently (nineteen lesions), closely followed by eighteen injuries to the superficial femoral artery and fourteen injuries to the brachial artery. In managing both false aneurysms and arteriovenous fistulas, repair of the arterial injury was the major objective. However, particular effort was made to repair larger veins in the arteriovenous fistula category. Patients with arterial thrombosis and stenosis who had symptoms interfering with their daily activity have had successful vascular reconstruction utilizing a variety of technics. No operative or related postoperative deaths occurred in this group of patients. There was only one early postoperative graft occlusion, (0.7 per cent of the operations) and two late graft occlusions (1.5 per cent). Subsequently, additional vascular reconstruction was successful.
Twenty-seven patients with peripheral vascular disease had studies of thrombin generation, antithrombin III -alues, factor VIII values, platelet adhesitivity, and activated partial thromboplastin time. Of the studies performed, the thrombin generation index, antithrombin III values, and, to a lesser extent, activated partial thromboplastin time were reliable in confirming clinically suspected hypercoagulability. When patients were placed into groups with and without operative complications, it was noted that the group with operative complications had higher average values of thrombin generation index and lower average values of antithrombin III and activated partial thromboplastin time than did the group without operative complications. It is thought that these tests may be useful in selecting those patients with a high risk of thrombotic complications from vascular surgery and who may benefit from anticoagulant management while undergoing necessary vascular reconstructive procedures.
1) Acute common femoral arterial injuries remain relatively uncommon in both military and civilian practice. 2) The recent experience in Vietnam has provided the most complete statistics regarding this type of injury. Among 1,000 acute major arterial injuries, the incidence of common femoral arterial trauma was approximately 5%. This present study reports 109 acute common femoral arterial injuries. Nearly two thirds of the injuries were caused by fragments and slightly more than one half of the injuries were lacerations. It was possible to perform autogenous vein graft repairs in about 57%, end-to-end anastomoses in about 25%, and lateral suture repair in about 10% of the injuries. Prosthetic material was used in only three repairs. 3) The overall complication rate was 28.3%, the amputation rate was 13.2%, and the mortality rate was 2.8%. 4) In the treatment of iatrogenic injuries associated with diagnostic catheterizations of the common femoral artery at Walter Reed Army Medical Center, there were no complications and no mortalities.
Through the Vietnam Vascular Registry which was established in 1966 at Walter Reed Army Medical Center, copies of medical records of 509 combat casualties with 558 arteriovenous fistulas and false aneurysms have been analyzed. This represents approximately 7 percent of the vascular injuries in American casualties from Southeast Asia, from 1963 to 1972, which are included in the Registry effort. Contributions of several hundred individuals are included in this documentation, however, more than one fourth of the patients, 149 or 29.3 percent, have been evaluated in our clinic. There were 296 false aneurysms and 262 arteriovenous fistulas. Multiple lesions occurred in 7.9 percent of the casualties. Fragment wounds accounted for 487 or 87.3 percent of the lesions with 85.5 percent in extremity vessels. Early recognition and definitive surgical treatment usually were accomplished: 52.8 percent within the first 30 days following injury. Ligation was either accepted or required in about 50 percent of the lesions. The mortality rate was 1.8 percent and the morbidity associated with the vascular injury was 6.3 percent. There were eight amputations for an amputation rate of 1.7 percent. Potential complications of heart failure, proximal arterial dilatation, and endocarditis were essentially absent.
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