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PubMed2000

The relation between lower extremity strength and shoulder overuse symptoms: a model based on polio survivors.

OBJECTIVE: To determine the relation between lower extremity weakness and shoulder overuse symptoms among polio survivors. We predicted that individuals with moderate weakness in their leg extensor muscles would use their arms to help compensate for this weakness and would be at high risk for developing symptoms of shoulder overuse. DESIGN: A cohort study of polio survivors recruited from the Einstein-Moss Postpolio Management Program (Philadelphia), the community, and the surrounding region. SETTING: A research laboratory at Moss Rehabilitation Research Institute, Philadelphia, PA. PARTICIPANTS: One hundred ninety-four polio survivors. Demographic and medical history data, symptom data, and strength data were obtained for each. MAIN OUTCOME MEASURES: Presence or absence of shoulder symptoms and ratings of pain by visual analogue scale were recorded. Strength was measured using a hand-held dynamometer and manual muscle testing. RESULTS: Shoulder symptoms could be grouped into two distinct clusters based on the type of testing used for assessment. Symptoms elicited by palpation were present in 26% of the subjects and were strongly related to knee extensor strength and weight. These symptoms were more common among women than men (42% and 10%, respectively). Symptoms elicited by resistance tests were present in 33% of the subjects and were seen with equal frequency in both sexes. These symptoms were also related to lower extremity strength, but the specific relationship was not as clear as for the palpation-related symptoms. CONCLUSIONS: Lower extremity weakness predisposes individuals to shoulder overuse symptoms. Sex and body weight are contributing factors. These results may be generalized to other populations with lower extremity weakness, including the elderly.

Adult↗
PubMed2003

Satisfaction with upper-extremity surgery in individuals with tetraplegia.

OBJECTIVE: To measure the satisfaction of individuals with tetraplegia with their upper-extremity reconstructive surgery. DESIGN: Survey. SETTING: Two Spinal Cord Injury Model Systems centers. PARTICIPANTS: Sixty-seven individuals with spinal cord injury at the C4 through C8 motor level (107 arms). INTERVENTIONS: Participants had upper-extremity surgery to improve function. The surgical procedures included tendon transfers for elbow extension, wrist extension, hand grasp, and pinch or hand grasp neuroprosthesis. MAIN OUTCOME MEASURE: A survey was mailed to participants, who were asked to respond to statements such as, "If I had it to do over, I would have the hand/arm surgery again," using a 5-level Likert scale (ranging from strongly agree to strongly disagree). RESULTS: Seventy percent of the participants were generally satisfied with the results of their upper-extremity surgery, 77% reported a positive impact on their lives, 68% reported improvements in activities of daily living (ADLs), 66% reported improved independence, 69% reported improvement in occupation, 71% reported improved appearance or neutral, 78% reported their hand worked as well (or neutral) as it did when surgery was first performed, and 86% reported postoperative therapy as being beneficial. CONCLUSIONS: Upper-extremity surgery had a positive impact on life, increased ability to perform ADLs and to be independent, and improved quality of life.

Activities of Daily Living↗
PubMed1997

Evaluation of a training program for persons with SCI paraplegia using the Parastep 1 ambulation system: part 5. Lower extremity blood flow and hyperemic responses to occlusion are augmented by ambulation training.

OBJECTIVE: To test whether 12 weeks of exercise conditioning using functional neuromuscular stimulation (FNS) ambulation alters the resting lower extremity blood flow and hyperemic responses to vascular occlusion in subjects with paraplegia, and to determine whether an association exists between limb flow and lower extremity fat-free mass. DESIGN: Pretest, posttest. SETTING: Academic medical center. PARTICIPANTS: Subjects with chronic neurologically complete paraplegia. INTERVENTION: Thirty-two sessions of microprocessor-controlled ambulation using electrically stimulated contractions of lower extremity muscles and a rolling walker. OUTCOME MEASURES: Subjects underwent quantitative Doppler ultrasound examination of the common femoral artery (CFA) before and after training. End-diastolic arterial images and arterial flow-velocity profiles obtained at rest and after 5 minutes of suprasystolic thigh occlusion were computer-digitized for analysis of heart rate (HR), CFA peak systolic velocity (PSV), CFA cross-sectional area (CSA), flow velocity integral (FVI), pulse volume (PV), and CFA (arterial) inflow volume (AIV). RESULTS: Significant effects of training on CSA (p < .0001), FVI (p < .05), computed PV (p < .001), and computed AIV (p < .01) were observed. Resting HR was lower following training (p < .05). The change for resting PSV approached but did not reach significance (p = .083). Analysis of postocclusion PV and AIV showed significant effects for conditioning status (p values < .01), postcompression time (p values < .0001), and their interaction (p values < .01). At 1 minute after occlusion, the posttraining AIV response was 78.2% greater in absolute magnitude and 17.4% more robust when expressed as a percentage change from its resting value than before training. Significant correlations were found between thigh fat free mass and both AIV and PV (p values < .05). CONCLUSION: Exercise training using FNS ambulation increases the resting lower extremity AIV in individuals with paraplegia and augments the hyperemic response to vascular occlusion. Improved posttraining blood flow is attributable both to vascular structural changes and upregulation of vascular flow control mechanisms. Limb mass is associated with the volume of arterial blood flow.

Adult↗
PubMed1998

The Capabilities of Upper Extremity instrument: reliability and validity of a measure of functional limitation in tetraplegia.

OBJECTIVE: To evaluate the reliability and validity of the Capabilities of Upper Extremity (CUE) instrument, designed to measure upper extremity functional limitations in individuals with tetraplegia. Functional limitations are actions such as reaching or grasping and are a link between the domains of impairment and disability. DESIGN: Survey of people with chronic spinal cord injury. SETTING: Regional spinal cord injury center. SUBJECTS: One hundred fifty-four individuals (140 male) with tetraplegia at least 1 year after injury and followed by the center. Mean age was 36.7 years (SD=11.1). Sixty-eight percent were motor complete. METHODS: The 32-item CUE was administered by telephone interview twice about 2 weeks apart. The motor portion of the Functional Independence Measure (FIM) was collected during the first interview. Upper extremity motor scores and motor levels were obtained from the most recent assessment in the outpatient chart. The instrument was evaluated for internal consistency, reliability, and validity. Exploratory factor analysis was performed to examine scale structure. RESULTS: Homogeneity of the scale was excellent. Cronbach's alpha was .96, and item-total correlations ranged from .49 to .78. Test-retest reliability was high (ICC=.94). All but three items had desired levels of agreement (K > .60). Analysis of variance indicated that the CUE distinguished between motor levels of tetraplegia more than one level apart. The CUE was correlated highly with both motor scores and FIM. Regression analysis indicated that the CUE was better than upper extremity motor scores for predicting FIM scores. The model containing the CUE explained 73% of the variance in FIM and was not enhanced by the addition of motor scores. Factor analysis suggested four potential subscales: arm function (bilateral), right hand function, left hand function, and reaching down. CONCLUSION: The CUE exhibits good homogeneity, reliability, and validity; further work is needed to determine its sensitivity to change in function.

Activities of Daily Living↗
PubMed1980

Comments on the functional asymmetries of the lower extremities.

Several tasks have been used to establish laterality in the lower extremities, but most of them are not satisfactory. The lower extremities are involved in various posturomotor, locomotor and operant activities, and several kinds of differentiated bilateralizations of the lower limbs can be identified. A distinction between leggedness and footedness seems warranted. The complexity of the functional asymmetries of the lower extremities requires new methods in both research and clinical testing, with elecctrophysiological procedures as a promising approach. Available evidence indicates that the functional asymmetries of the axial neuromotor mechanisms have to be considered in the study and the assessment of those of the lower extremities.

Conditioning, Operant↗
PubMed1998

Management of extremely low birth weight infants: perceptions of viability and parental counseling practices.

OBJECTIVE: To determine physician opinions, parental counseling, and medical practices for extremely low birth weight (LBW) infants. METHODS: A retrospective survey was sent in August 1996 to 450 California physicians practicing obstetrics. RESULTS: There was a 41% response rate. The mean thresholds for antenatal steroid administration, cesarean delivery for fetal distress and delivery room resuscitation were gestational age between 23 and 24 weeks and weight close to 500 g. Most obstetricians counsel parents regarding survival, resuscitation, and possible death in the delivery room before delivery of an extremely LBW infant. Just over 60% of obstetricians believe that parents have a role in deciding not to resuscitate an infant born at 22 weeks' gestation, this decreases to less than 50% at 24 weeks, and decreases further to less than 30% by 26 weeks' gestation. Just over 40% of obstetricians report their counseling is affected by pediatric opinion, 33% by previous maternal perinatal losses, and less than 20% by maternal drug use or lack of prenatal care, and young maternal age. Language barriers, parental education level, and family insurance affect treatment options in less than 10% of obstetricians. CONCLUSION: Obstetric opinions about delivery room resuscitation of extremely LBW infants are influenced by birth weight and gestational age thresholds, infant, and parental factors. There is a limited willingness by physicians to allow a parental role in decision making in the delivery room for extremely LBW infants.

Adult↗
PubMed1997

Role of venous duplex imaging of the lower extremities in patients with fever of unknown origin.

BACKGROUND: Although a fever of unknown origin (FUO) is most often due to other causes, the few caused by pulmonary emboli, pelvic thrombophlebitis, or lower extremity venous thrombosis (DVT) present a diagnostic challenge. The purpose of this study was to evaluate the role of venous duplex imaging of the lower extremity in evaluating a large series of patients with FUO. This has not been reported previously in the English-language literature. METHODS: Medical records were analyzed of patients with FUO who were referred to the vascular laboratory for venous duplex imaging of the lower extremities to rule out DVT as a cause of their fever. A FUO was defined as a temperature of greater than 38.3 degrees C on several occasions for at least 3 weeks' duration that defied 1 week of hospital evaluation. DVT was considered as a probable cause of FUO if the following criteria were met: (1) a positive venous duplex image for acute DVT, (2) subsequent fever resolution within 7 days of anticoagulation therapy, and (3) a fever that was resistant to prior treatment. RESULTS: A total of 114 duplex examinations, gathered during a 2-year period, were analyzed. The 89 patients had a mean age of 58 years. Infections were the most common cause of FUO (57 of 89, 64%), and unknown causes constituted 19%. There were seven cases of DVT (8%), five (6%) of whom met the criteria for probable cause of FUO. The overall cost of venous duplex imaging examinations was $51,300 ($450 x 114 tests), with an average cost of $10,260 for each case of DVT detected as probable cause of FUO. CONCLUSIONS: Consistent with the literature, infections remain the most common cause of FUO; however, DVT was found to be a more common cause of FUO in our present series (6%). The cost of venous duplex imaging of the lower extremities in establishing DVT as a probable cause of FUO should be borne in mind when the work-up of these patients is planned.

Adult↗
PubMed2000

Energy expenditure in the extremely low-birth weight infant.

Information about energy requirements of extremely low-birth weight infants is sparse, despite the rapidly improving survival rates of this population. Metabolizable energy intake can be estimated from energy balance studies and the percentage of caloric intake that is actually absorbed by these infants is approximately 87%. Data on energy expenditure in extremely premature infants is limited; however, energy expenditure has been shown to increase with postnatal age. Because both intake and expenditure are affected by multiple factors, there is significant variability in estimates of the energy requirements in extremely low-birth weight infants. At present, no valid recommendations can be made regarding optimal energy requirements for the extremely low-birth weight infant, except that their requirements probably exceed those of stable, growing very low-birth weight infants, currently estimated at 105 to 135 kcal.kg-1d-1.

Energy Intake↗
PubMed1990

Relative bradycardia in patients with isolated penetrating abdominal trauma and isolated extremity trauma.

A relative bradycardia is sometimes seen in patients with hemorrhagic shock. The phenomenon of relative bradycardia in civilian patients with isolated penetrating abdominal trauma and isolated severe extremity trauma who presented to an urban trauma center was studied retrospectively. Relative bradycardia was defined as a pulse rate of less than 100 with a concomitant systolic blood pressure of less than 100 mm Hg. There were 256 patients with isolated penetrating abdominal trauma and 938 patients with isolated severe extremity trauma. The incidence of relative bradycardia was 3.1% (eight of 256) in the group with abdominal trauma and 1.8% (17 of 938) in the group with extremity trauma. A pulse rate less than 100 was documented in 35.2% of all patients presenting with a systolic blood pressure less than 100 mm Hg (25 of 71). A pulse rate of less than 100 was documented in 45.8% of all patients presenting with a systolic blood pressure less than 90 mm Hg (11 of 24). No increased mortality was seen in the patients who evidenced relative bradycardia. The effect of intraperitoneal bleeding on the normal tachycardic response to hemorrhage also was studied. After controlling for volume status using various operational definitions of shock, no statistically significant (P less than .01) difference in pulse rates was noted between patients with isolated penetrating abdominal trauma and isolated extremity trauma. This result suggests that the previously theorized vagal-mediated bradycardia unique to intraperitoneal bleeding may not exist.

Abdominal Injuries↗
PubMed1997

EMLA versus TAC for topical anesthesia of extremity wounds in children.

STUDY OBJECTIVE: To compare the anesthetic efficacy of EMLA (eutectic mixture of local anesthetics) cream with that of TAC (tetracaine, adrenaline, and cocaine) solution for suturing uncomplicated extremity wounds. METHODS: We conducted a prospective, single-blind, randomized trial in a convenience sample of 32 children, ages 5 to 18 years, who required repair of an extremity laceration. Eligible wounds were less than 5 cm long and less than 12 hours old. Lacerations involving digits, deep tissues, or musculature were excluded. Patients receiving medications that predisposed them to methemoglobinemia were also excluded. Lacerations were treated with TAC .1 mL/kg (maximum, 3.0 mL) or EMLA .15 g/kg (maximum, 5.0 g). Anesthesia was assessed every 10 minutes. TAC and EMLA were allowed to remain on the wounds for a maximum of 30 and 60 minutes, respectively. Anesthesia was deemed successful if no supplemental lidocaine was required, as judged by a suturing caregiver who was blinded to the anesthetic used. RESULTS: The two groups were similar with regard to age, sex, wound length and depth, and wound age. EMLA-treated wounds were repaired without supplemental anesthesia more often than TAC-treated wounds: 13 of 16 (85%) versus 7 of 16 (45%, P= .03). More time was required for EMLA to cause anesthesia (55 versus 29 minutes, P<.01). Dehiscence occurred in one wound in each group; no wound infections were observed. CONCLUSION: EMLA appears to be superior to TAC for anesthesia of simple extremity lacerations in that those wounds treated with EMLA required supplemental anesthesia less often. EMLA required approximately 1 hour to cause optimal anesthesia in open wounds. Protocols should be developed to allow efficient use of EMLA for anesthesia of extremity lacerations in the ED.

Adolescent↗
PubMed2000

The effects of the lower extremity joint motions on the total body motion in sit-to-stand movement.

OBJECTIVE: The purpose of this study is to investigate the effects of lower extremity joint angular motions on the whole body linear motions in a sit-to-stand movement using a biomechanical model that describes the whole body linear velocity vector as functions of lower extremity joint angular velocities. DESIGN: Two-dimensional video analysis of whole body and joint kinematics. BACKGROUND: A biomechanical model that describes the whole body linear motions as functions of lower extremity joint angular motions is needed to provide clinically relevant information in clinical services and scientific research. METHODS: The linear velocity vector of the whole body motion during the sit-to-stand movement was partitioned into horizontal and vertical components and expressed as functions of lower extremity joint angular velocities for 10 healthy subjects. The coefficient of joint contribution to the whole body linear velocity vector was determined for each joint in each direction. RESULTS: The ankle and hip angular motions are critical to the development of the forward horizontal velocity of the whole body during the sit-to-stand movement. The knee and hip angular motions are critical to the development of the upward vertical velocity of the whole body during the sit-to-stand movement. CONCLUSIONS: The hip, knee, and ankle joint angular motions have various roles in whole body motions in different directions of the sit-to-stand movement. RELEVANCE: The model and the results of this study can be applied to study the control strategies, falls, and assessments of functional impairments in the sit-to-stand movement.

Adult↗
PubMed1998

Putting risk in its place: methodological considerations for investigating extreme event health risk.

Health is affected by the places in which people live, work and interact, yet many epidemiological studies overlook the characteristics of places and instead focus solely on the people who inhabit them. Place-based investigations of disparities in health outcomes are concerned with the healthiness of places and not merely the healthiness of the populations in these places. A place-based approach has been used within medical geography and medical sociology, typically in the study of health differentials associated with long-term, cumulative exposures to a wide range of environmental variables. This approach has rarely been extended, however, to health research that looks at the effects of extreme events (such as industrial accidents or hurricanes). The purpose of this paper is to incorporate a place-based framework into extreme event health research. The paper first discusses methodological considerations for a place-based approach and then illustrates the use of spatial analysis techniques as the first step in identifying place-based risk factors in mortality associated with heat waves. The study centers on St. Louis, Missouri, a city where heat waves are frequent and heat-related mortality is high. The results show that heat-related mortality rates during the most severe heat waves were generally higher in the warmer, less stable and more disadvantaged areas of St. Louis and lower in the cooler and more affluent parts of the city. During the milder years analyzed, there was little evidence of a relationship between place-based characteristics and the distribution of heat-related mortality. These findings about extreme event mortality risk would not have been evident from a population-based analysis. Ongoing dialog between epidemiologists and social scientists can help to bring place into the arena of extreme event research and to increase understanding of the role of place in risk.

Health Status Indicators↗
PubMed1984

Evaluation of vascular compromise in the injured extremity: a photoplethysmographic technique.

A monitoring technique in which an infrared photoplethysmograph (PPG) is used to assess the vascular status of injured extremities is described. PPG has been correlated with blood flow in the forearm muscle and direct measurements of compartment pressure. These studies show a significant decrease in amplitude of the PPG signal with diminished blood flow in muscle and with compartment pressures greater than 40 mm Hg. We used PPG clinically on 55 extremities injured by direct vascular trauma, crushing forces, or severe burns. Although clinical signs suggested use of escharotomy in six of 29 burned extremities, normal PPG signals were present and conservative management resulted in no long-term morbidity. Three limbs had moderate pulsatile flow shown by PPG that significantly diminished over a period of 12 to 24 hours even though Doppler flow signals remained strong. Good pulsatile flow was restored in all cases after early escharotomy . PPG monitoring of vascular status is simple and reproducible and accurately reflects levels of ischemia in injured extremities.

Adult↗
PubMed1986

Interscalene brachial plexus block anesthesia for upper extremity surgery.

Use of the interscalene brachial plexus block for upper extremity anesthesia in a primarily rheumatoid population is reviewed in 88 cases. The interscalene approach described by Winnie was used. Anesthesia was effective in 93% of the cases. Failure to achieve anesthesia was more likely to occur in surgical procedures on the distal upper extremities. The technique allowed effective and reliable anesthesia throughout the upper extremity, including the shoulder. Problems associated with other forms of upper extremity regional anesthesia, such as tourniquet pain, pneumothorax, systemic anesthetic toxicity, and inadequate duration of anesthesia, were not encountered. Difficulties with more distally based block administration due to decreased shoulder motion were obviated.

Anesthetics, Local↗
PubMed2004

Endovascular stent placement in the treatment of upper extremity central venous obstruction in hemodialysis patients.

OBJECTIVE: To evaluate the efficacy of stent placement for treating upper extremity central venous obstruction in chronic hemodialysis patients. METHODS AND MATERIAL: Between January 1999 and October 2001, we inserted metallic stents into the upper extremity central veins of 14 patients with shunt dysfunction and/or arm swelling. The indications for stent placement were stenosis or occlusion of the central vein in the upper extremity used for dialysis. Six of the individuals were diagnosed with subclavian vein stenosis, and 5 with brachiocephalic vein stenosis. Of the remaining 3 patients, 2 had subclavian vein occlusion, and 1 had left brachiocephalic vein occlusion. RESULTS: All the stent placement procedures were technically successful, and there were no major complications. Follow-up ranged from 2 weeks to 29 months. The 1-, 3-, 6- and 12-month primary stent patency rates were 92.8, 85.7, 50 and 14.3%, respectively. Repeat interventions, including percutaneous transluminal angioplasty and additional stent placement, were required in 9 patients. The 3-, 6-, 12-month, and 2-year assisted primary stent patency rates were 100, 88.8, 55.5 and 33.3%, respectively. CONCLUSION: Endovascular stent placement is an effective alternative to surgery in patients with shunt dysfunction due to obstruction of an upper extremity central vein. Repeated interventions are usually required to prolong stent patency.

Adolescent↗
PubMed1995

Screening for abdominal aortic aneurysms during lower extremity arterial evaluation in the vascular laboratory.

PURPOSE: The purpose of this study was to evaluate the cost-effectiveness of screening for abdominal aortic aneurysms (AAA) during noninvasive lower extremity arterial examination in the vascular laboratory. METHODS: Over 30 months we screened 531 patients who underwent lower extremity arterial evaluations in the vascular laboratory. The patients had fasted overnight, and, after the regular noninvasive lower extremity arterial examination, the abdominal aorta was screened with B-mode ultrasonography. RESULTS: The aorta was adequately visualized in 475 patients (89%). Mean aortic diameter was 19.6 +/- 4.1 mm at the juxtarenal level and 18.8 +/- 7.2 mm in the lower infrarenal aorta. The aortic diameter was larger in men (p < 0.001) and in smokers (p < 0.001). AAA (diameter greater than 3.0 cm) were identified in 32 patients (6.0% of the 531 patients screened), and 15 of the aneurysms were equal to or larger than 4.0 cm. The best predictors for AAA by logistic regression analysis were male sex (p < 0.005), advanced age (greater than 65 years, p < 0.01), and a history of smoking (p < 0.01). The prevalence of AAA was 6.7% (32/475) in the population in whom the aorta was visualized and 15.2% (19/125) in male smokers over 65 years of age. Aneurysms of 4.0 cm or greater were identified in 3.2% of the entire population screened and 8.8% of male smokers over age 65. Limited aortic scanning prolonged the vascular laboratory examination by an average of 5 minutes. Thus detection of one aneurysm required 83 minutes of scanning time for the whole population studied and 36 minutes of scanning of male smokers over age 65, at a cost of $240 to $553 per aneurysm identified. CONCLUSION: Screening for AAA during lower extremity arterial evaluation in the vascular laboratory addresses a high-risk population, is cost-effective, and should be considered an appropriate and valuable addition to the examination protocol.

Aged↗
PubMed1995

Progression of atherosclerosis in arteries distal to lower extremity revascularizations.

PURPOSE: The characteristics of progression of atherosclerotic occlusive disease (AOD) of the lower extremities after revascularization are unknown. Duplex scanning or angiography were used to determine progression in 150 patients after they underwent revascularization for AOD. METHODS: Follow-up studies were compared with presurgical arteriograms. Superficial femoral (SFA) and popliteal arteries were graded as less than 50% stenosis, 50% to 99% stenosis, or occluded. Tibial arteries were graded with regard to whether they were continuously patent from the popliteal trifurcation to the ankle. Progression was defined as an increase in one stenosis category. RESULTS: At a mean follow-up of 4.8 years, 18% of native arteries, 39% of extremities, and 52% of patients demonstrated progression of AOD. Overall, 21% of arteries in patients undergoing infrainguinal bypass and 14% of arteries in patients undergoing suprainguinal bypass demonstrated progression (p = 0.004). Progression was more frequently detected in examinations performed more than 4 years after baseline arteriography (66%) than in examinations performed 6 months to 2 years (45%, p = 0.032) or 2 to 4 years (44%, p = 0.029) after baseline arteriography. Thirty percent of SFAs demonstrated progression, and 32% with 50% stenosis or greater at baseline became occluded. There was no difference in SFA, popliteal, or tibial artery progression in revascularized versus nonrevascularized extremities after suprainguinal bypass. There was no difference in tibial artery progression in operated and nonoperated limbs after femoropopliteal artery bypass. CONCLUSIONS: AOD progression occurs frequently in patients requiring revascularization and is more prevalent in patients requiring femoropopliteal than in patients requiring suprainguinal bypass. AOD progression in patients undergoing vascular surgery is associated with the pattern of disease producing lower extremity ischemia and does not appear to be worsened by arterial reconstruction.

Adult↗
PubMed1997

Utility of magnetic resonance arteriography for distal lower extremity revascularization.

PURPOSE: Magnetic resonance arteriography (MRA) of the lower extremities affords several possible advantages over conventional contrast arteriography (CA). We hypothesized that MRA of the infrageniculate vessels was sufficiently accurate to replace CA before revascularization procedures in patients with limb-threatening ischemia. METHODS: Fifty-three extremities in 49 patients were prospectively evaluated before attempted infrageniculate revascularization procedures with preoperative infrageniculate time-of-flight MRA (cost, $170/study) and standard contrast arteriography (cost, $1310/study) of the aortoiliac and runoff vessels. Independent operative plans were formulated based on the MRA and CA results before the revascularization procedure. Intraoperative, prebypass arteriograms (IOA; cost, $46/study) were obtained in all patients to confirm the adequacy of the distal runoff. The preoperative plans formulated by the results of MRA and CA were compared with the actual procedure performed based on the IOA. All arteriograms (CA, MRA, IOA) were reviewed after the operation by two independent reviewers, and the number of patent vessel segments and those with < 50% stenosis was determined. RESULTS: Revascularization procedures were performed in 44 of 53 extremities (83%), and amputation was performed in nine extremities (17%) because of an absence of a suitable bypass target. The CA and MRA were equally effective in predicting the optimal operative plans as determined from IOA (CA, 42 of 53 [77%] vs MRA, 40 of 53 [75%]; p = 0.79). More patent vessel segments were seen on CA than MRA (reviewer A, 229 vs 174, kappa = 0.32; reviewer B, 321 vs 314, kappa = 0.46); however, a comparable number of segments were seen if the vessels of the foot were excluded. The accuracy (reviewer A, 78% vs 68%, p = 0.003; reviewer B, 75% vs 67%, p = 0.003) and sensitivity (reviewer A, 69% vs 51%, p = 0.001; reviewer B, 68% vs 46%, p = 0.0001) of CA relative to IOA were superior to those of MRA, although the specificity was comparable (reviewer A, 86% vs 90%, p = 0.31; reviewer B, 82% vs 87%, p = 0.52). The combination of MRA and IOA would have resulted in the optimal operative plan in 51 of the 53 cases (96%) and was comparable with CA and IOA (53 of 53; 100%; p = 0.50). Substitution of MRA and IOA for CA and IOA could potentially have saved an estimated $60,420. CONCLUSIONS: The combination of MRA and IOA provides an accurate, cost-efficient strategy for visualization of the infrageniculate vessels before revascularization procedures.

Aged↗