[Distal blood pressure--how and how often?].
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Blood Pressure Determination↗
Biomedical subjects
P Holstein
Publications and source records attributed to P Holstein.
Thromboembolectomy in geriatric patients from long-stay wards.
The results of arterial embolectomy with the Fogarty balloon catheter in patients over 70 years of age with acute ischaemia of the lower limbs were evaluated. Twenty-three geriatric patients from long-stay wards, median age 81 years, range 70-92, were compared with 45 independent patients, median age 81 years, range 70-91, living in their own homes. The period of ischaemic symptoms before admission was on average shorter for patients coming from long-stay wards, but the outcome was less successful. Recurrent occlusion during the first postoperative month took place in 12 patients (52%) from long-stay wards as compared to eight (18%) among independent patients (p < 0.01). The mortality was 35% and 18% respectively (p > 0.2). After six months, only 35% of patients from geriatric institutions were alive with a functional extremity as compared to 62% in the independent group (p > 0.01).
Aged↗
Percutaneous transluminal angioplasty in 226 iliac artery stenoses: role of the superficial femoral artery for clinical success.
We reviewed the results of 174 consecutive percutaneous transluminal angioplasties (PTA) for 226 iliac artery stenoses (mean length 1.6 cm, range 0.2-9.6 cm) in 150 patients with lower limb ischaemia. Vascular intervention was indicated by intermittent claudication in 123 and critical ischaemia in 51 (29%) limbs. There were 12 (7%) failed guide-wire recanalizations. Four (2%) serious complications from puncture site haemorrhages or peripheral embolizations were handed surgically and caused one major amputation. Five-year patency in 162 successful dilatations was 68% primarily and 81% secondary to vascular surgical reconstructions during an average 28 (range 1-60) months of observation. One hundred and thirteen (70%) limbs improved clinically. In 95 limbs treated exclusively by iliac PTA, clinical improvement was achieved in 38/47 (81%) limbs with patency and 24/48 (50%) limbs with occlusion of the superficial femoral artery (SFA) (p < 0.003), whereas vascular patency of iliac PTA was unaffected by status of the SFA. Five-year limb salvage rate was 50% in limbs with critical ischaemia. We conclude that PTA for iliac artery stenoses is a low-risk procedure offering acceptable clinical results provided the SFA is patent. As an adjunct to distal bypass surgery, iliac PTA improves inflow without the requirement for major aorto-iliac surgery and may extend indications for vascular intervention in patients with lower limb ischaemia.
Adult↗
Femoro-popliteal artery occlusions treated by percutaneous transluminal angioplasty and enclosed thrombolysis: results in 55 patients.
Removal of fibrin from the site of a newly dilated femoro-popliteal occlusion may be an attractive way of preventing rethrombosis. A double balloon catheter with a dilating tip balloon and an occlusive balloon 10, 15 or 20 cm approximately were introduced percutaneously. Following successful dilatation of femoro-popliteal occlusions, the balloons were inflated on both sides of the lesion. The dilated segment was then isolated from the circulation. Through a sideport between the balloons 5 mg of tissue type plasminogen activator and 1000 IU of heparin were installed within the segment for 30 min. The authors report the results of 53 technically successful dilatations of femoro-popliteal occlusions followed by enclosed thrombolysis. A 100% patency at 3 months was noted in 33 patients having one to three run-off arteries, and the one year patency was 90%. In 20 patients, with no infrapopliteal run-off artery, four rethrombosis occurred within 24 h, and the one year patency was 62%. This difference is significant. (Log rank test, Chi-square = 4.73, p less than 0.05). We conclude that enclosed thrombolysis prevents early reocclusion following PTA of femoro-popliteal occlusions provided that at least one infra-popliteal artery is patent.
Aged↗
The results of completion angiography after acute lower limb thromboembolectomy.
The results of completion angiography after acute thromboembolectomy with a Fogarty balloon catheter were evaluated. There were 62 patients (median age 72 years, range 44-92 years) and completion angiograms were made in 44 of them (71%). Incomplete runoff was demonstrated in 26 patients (59%) and rethromboembolectomy or vascular reconstruction was made in 18 cases (41%) under the same anaesthesia, while additional vascular surgery was technically impossible in 8 patients (18%). Supplementary surgery resulted in radiological improvement in 56% of operated cases. Reocclusion rate after 6 months was 50% in patients without patent tibials compared to 15% in patients with two or three patent tibial arteries (P less than 0.05). Eighteen patients had no completion angiograms after thromboembolectomy and 5 (28%) required early reoperation due to ischaemia. Completion angiograms are advocated in all cases of acute thromboembolectomy before the patient leaves the operating table.
Acute Disease↗
Early rethrombosis in femoropopliteal occlusions treated with percutaneous transluminal angioplasty.
One hundred and thirty-seven consecutive percutaneous transluminal angioplasties (PTA) were performed for femoropopliteal vascular disease including 58 stenoses and 79 total occlusions. Nine occlusions could not be crossed with the guidewire, but in the remaining 128 the haemodynamic and clinical success as well as vascular patency were evaluated. The results were grouped into the following subsets: the indication for PTA, the severity of the vascular lesion, the crural run-off and the length of lesion. The results were in every respect poor with total occlusions when compared with stenoses. This was explained by a high incidence (41%) of rethrombosis within hours of dilatation. Early rethrombosis was seen with all lengths of occlusion (1-27 cm) with no statistically significant difference from other subsets. This study concludes that conventional PTA in femoropopliteal occlusions should be reserved for cases of limb salvage, preferably in patients who are technically inoperable. We suggest a new technique of segmentally enclosed thrombolysis to prevent early rethrombosis after PTA in femoropopliteal occlusions.
Aged↗
Outcome in 282 lower extremity amputations. Knee salvage and survival.
Lower-extremity amputation for arterial insufficiency was performed in 282 cases ineligible for vascular surgery. In 203 cases (Group I), amputation was elective without previous vascular surgery. In 14 cases (Group II), amputation followed recent vascular reconstruction, and in 12 cases (Group III) amputation was performed after failed thromboembolectomy. In 53 cases (Group IV), amputation was done acutely, i.e., as a life-saving procedure because of septicemia. The results as regards both knee salvage and survival were much better in Groups I and II than in Groups III and IV. We conclude that knee salvage is poor and mortality high after acute amputations and after failed thrombembolectomy. These factors should be taken into account when comparing series from different centers.
Adult↗
Prognostic significance of digital blood pressure in leg ulcer patients.
In a consecutive series of patients with ulceration of the lower leg referred to the dermatological in-patient department during a 9-month period, a systolic digital blood pressure level (SDBP) below 60 mmHg was used to identify patients with complicating arterial occlusive disease (AOD) of the legs. AOD was diagnosed in 25 patients and stasis ulcers from venous disease (SDBP greater than or equal to 60 mmHg) in 38 patients of the same ages. Patients with ulceration from other causes were excluded. After 1 year, 48% of the patients with AOD and 5% of those with stasis ulcers had died. In the AOD group, 11 legs were amputated. Our figures show that the SDBP is valuable in identifying high-risk patients.
Adult↗
Aorto-femoral digital subtraction angiography in old patients with symptoms of peripheral arterial disease. Findings, efficacy, and consequences.
Seventy-four patients between the ages of 75 and 88, with disabling intermittent claudication or critically ischaemic legs underwent an aorto-femoral digital subtraction angiography (DSA). Thirty-six procedures were intraarterial and 38 were intravenous. There were no major complications. The degree and localisation of the arterial lesions did not differ from earlier reports based on conventional arteriography. In 67 patients, on the basis of the DSA examination, a decision could be made as to whether vascular surgery was feasible. In 28 of 57 non-diabetic patients (49%), invasive treatment was carried out in the form of vascular reconstruction, thromboembolectomy, or percutaneous transluminal angioplasty. None of the 17 diabetic patients could be treated invasively.
Aged↗
Femoral artery recanalisation with percutaneous angioplasty and segmentally enclosed plasminogen activator.
To establish whether re-occlusion of the femoral artery could be prevented, in 6 consecutive patients undergoing percutaneous transluminal angioplasty (PTA) for superficial femoral artery occlusion the recanalised segment was isolated, with a 7-French double-balloon catheter. 5 mg recombined human tissue-type plasminogen activator (rt-PA) and 1000 IU heparin were then infused into the enclosed space for 30 minutes, followed by intravenous heparin for 24 hours. At 10 and 30 days all 6 patients had evidence of recanalisation and remission of symptoms. Mean ankle-arm pressure index improved by 72% at 24 hours, by 118% at 10 days, and by 103% at 30 days after the procedure. No patients had major complications. Treatment of superficial femoral artery occlusions by PTA with rt-PA and intravenous heparin seems to prevent rethrombosis.
Aged↗
The ischaemic leg: a long-term follow-up with special reference to the predictive value of the systolic digital blood pressure. Part I: No arterial reconstruction.
The course of 53 patients presenting with 76 legs with ischaemia, defined by blood pressure on the big toe below 30 mmHg, were investigated. The series consists of those patients who after an angiography were considered non-candidates for arterial reconstructive surgery. There were 38 limbs with low pressure and severe ischaemic symptoms, i.e. rest pain and/or gangrene and 38 limbs with low pressures and only intermittent claudication or no leg symptoms at all. There were statistically significant differences in the fate of the limbs in the two groups, the first group suffering a 68 per cent risk of amputations compared to only 16 per cent in the second group. The corresponding risk of death was approximately 60 per cent and 10 per cent. The social fate was poor in the group with rest pain and/or gangrene due to the high number of amputations.
Adult↗
The ischaemic leg: a long-term follow-up with special reference to the predictive value of the systolic digital blood pressure. Part II: After arterial reconstruction.
Ninety-five patients with 122 legs with a systolic blood pressure on the big toe below 30 mmHg were the subject of arterial reconstructive surgery. Investigating the limb survival rate we found the systolic blood pressure on the big toe to be the most important predictor, whereas there was found no predictive value of the ankle pressure/index. Preoperative clinical symptoms, which are closely related to the digital blood pressure, were significant predictors of the limb survival rate: the low-pressure limb with no symptoms or intermittent claudication had a significantly higher survival rate than the limb with rest pain and/or gangrene. Following arterial reconstructive surgery the social fate of patients with threatened legs was fairly good as 83% became fully independent.
Adult↗
Limb salvage in diabetics with foot ulcers.
The healing results in 491 ulcers in 272 diabetic patients are reported. Soft moulded insoles and shoe corrections were the main part of the therapy. There were 329 (67%) neuropathic, 87 (17%) traumatic, 44 (9%) ischaemic and 31 (6%) ulcers of other various pathogenesis. Thirty seven per cent of the ulcers were complicated with invasive infection. Within the period of observation of 18 months (3-39 months) healing was obtained in 79% of the patients (88% of the ulcers) and major amputation was carried out in 8% (4% of the ulcers). There were 21 major amputations, which in 18 cases was due to ischaemia. Thus in only 3 cases (1% of the patients) neuropathy as complicated by invasive infection caused major amputation. Fifty nine ulcers (12%) were classified as relapsing ulcers or ulcers with new localizations and were caused by severe deformity of the foot (58 cases) often in combination with neglect of prophylaxis (7 cases). Only one recurrent ulcer was caused by ischaemia. The series shows that shoe corrections and insoles are effective in treating diabetic neuropathic ulcers. Recurrent ulcerations are caused by severe foot deformity and neglect of therapy. Loss of limbs is caused by ischaemia and invasive infection.
Adult↗
The cause of ischaemic nocturnal rest pain.
Adipose tissue blood flow in the forefoot was measured simultaneously with mean systemic arterial blood pressure over 24 hours in 8 patients (15 feet) with different degrees of arterial insufficiency. Mean systemic arterial pressure decreased by 19 +/- 9% during sleep, irrespective of symptomatology. In two limbs, with a normal peripheral circulation, blood flow decreased by 8 +/- 7%. In five limbs with arterial insufficiency, but no rest pain, blood flow decreased by 16 +/- 8% and in eight limbs with ischaemic nocturnal rest pain blood flow was reduced by 32 +/- 12% during sleep. It is concluded that nocturnal hypotension is a major factor in the production of nocturnal ischaemic rest pain.
Aged↗
Abnormal extension of the big toe as a cause of ulceration in diabetic feet.
Relief from external pressure and repetitive stress is a main concept in treating diabetic neuropathic ulcers. Ulcers on the tip of the big toe may be caused by abnormal extension of the big toe, which can be diagnosed only by observing the patient during barefoot walking. A flexor pad underneath the big toe eliminates the phenomenon, but in case of rigidity of the toe, extremely roomy toe boxes must be prescribed. Out of a series of 272 diabetic patients with skin lesions on the feet 18 suffered this phenomenon, in one case with bilateral ulcerations. Fifteen ulcers healed and below the knee amputation had to be carried out in 4 legs due to ischaemia.
Diabetic Neuropathies↗
Why do patients with severe arterial insufficiency get pain during sleep?
Simultaneous measurement during 24 h of mean arterial blood pressure (MABP) and forefoot subcutaneous adipose tissue blood flow (SBF) was undertaken in eight patients (15 feet) with different degrees of arterial insufficiency. The recordings were undertaken with the patients in the supine position only. The MABP decreased by 19 +/- 9% from awake to asleep independently of symptomatology. In two limbs with normal circulation, SBF decreased by 8 +/- 7%. In five limbs with arterial insufficiency but no rest pain SBF decreased by 16 +/- 8%, and in eight limbs with ischaemic nocturnal rest pain, SBF was reduced by 32 +/- 12% during sleep. It is concluded that nocturnal hypotension is the major aethiological factor for the symptom ischaemic nocturnal rest pain.
Adipose Tissue↗
Measurement of cerebral blood flow by intravenous xenon-133 technique and a mobile system. Reproducibility using the Obrist model compared to total curve analysis.
The recent development of a mobile 10 detector unit, using i.v. Xenon-133 technique, has made it possible to perform repeated bedside measurements of cerebral blood flow (CBF). Test-retest studies were carried out in 38 atherosclerotic subjects, in order to evaluate the reproducibility of CBF level and side-to-side asymmetry. Data were analysed according to the Obrist model and the results compared with those obtained using a model correcting for the air passage artifact. Reproducibility was of the same order of magnitude as reported using stationary equipment. The side-to-side CBF asymmetry was considerably more reproducible than CBF level. Using a single detector instead of five regional values averaged as the hemispheric flow increased standard deviation of CBF level by 10-20%, while the variation in asymmetry was doubled. In optimal measuring conditions the two models revealed no significant differences, but in low flow situations the artifact model yielded significantly more stable results. The present apparatus, equipped with 3-5 detectors covering each hemisphere, offers the opportunity of performing serial CBF measurements in situations not otherwise feasible.
Adult↗