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Query: UMLS:C0022116 (ischemia)
 91,303 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

A 68-year-old man who presented with unstable angina had had cardiac bypass surgery 12 years earlier and successful angioplasty of a native circumflex lesion 18 months previously. Repeat catheterization showed a widely patent angioplasty site but interval closure of a saphenous vein graft to a large marginal branch that was totally occluded proximally. A stress test revealed significant myocardial ischemia. Severe peripheral peripheral vascular disease with known bilateral iliac artery occlusions mandated a brachial approach. Because of his high risk for repeat cardiac surgery, it was elected to attempt saphenous graft angioplasty following a prolonged urokinase infusion. After an infusion of urokinase for 36 hr, antegrade flow was restored and angioplasty was carried out successfully on a discrete mid-graft legion. Subsequent stress testing showed resolution of the ischemia. There were no vascular complications.
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PMID:Successful angioplasty of a chronically occluded saphenous vein graft using a prolonged urokinase infusion from the brachial route. 207 Mar 99

In patients with coronary artery disease, angina pectoris provides an unreliable underestimation of disease activity and risk. Unheralded myocardial infarction and sudden death are common clinical presentations. Furthermore, objective testing, in hospital and more recently during the patient's normal daily activities, has demonstrated frequent and asymptomatic episodes of ischemia, as indicated by transient ST-segment depression. Since the underlying pathophysiologic disturbances of myocardial perfusion appear to be similar in painful and painless episodes, it seems appropriate to consider them together as the "total ischemic burden" on the myocardium. Research into this functional expression of coronary disease has indicated that active ischemia is associated with an increased risk of morbid events in all clinical subgroups of patients, including those with stable angina, unstable angina, peripheral vascular disease and following myocardial infarction. If this is confirmed in prospective trials, the assessment of total ischemic burden is likely to become part of the clinical investigation of patients with coronary disease. Clinical trials testing the efficacy of interventions will need to examine the effect on ischemic activity during normal daily life, in addition to symptoms and exercise tolerance. Evidence is still required to demonstrate whether therapy aimed at reducing the total ischemic burden will prolong life. The total ischemic burden provides a marker to follow the dynamic changes of the atherosclerotic lesion. Future research may have to concentrate on treatment aimed at altering the natural history of obstructive coronary atherosclerosis in order to affect the long-term outlook for patients with coronary artery disease.
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PMID:Total ischemic burden in patients with coronary artery disease. 209 78

To investigate the diagnostic value of carbon dioxide arteriograms in patients with peripheral vascular disease, ten patients in whom standard contrast arteriography was contraindicated underwent carbon dioxide digital subtraction arteriography. Lower extremity ischemia or severe hypertension with renal insufficiency were the indications for arteriography. Standard contrast arteriography was precluded by chronic nondialysis-dependent renal insufficiency, severe congestive heart failure or contrast hypersensitivity. All critical arterial segments were well visualized with the exception of the infrapopliteal arterial tree in three patients. Adequate imaging of this segment required the addition of 20 cc of dilute nonionic contrast. Guided by carbon dioxide digital subtraction arteriography, four percutaneous transluminal angioplasties and three reconstructive procedures were successfully performed. One patient did not have surgically reconstructible disease and two had renal arteries without critical stenoses. Renal function transiently deteriorated in one patient who received 20 cc of nonionic contrast. No adverse events occurred due to carbon dioxide. Clinically useful diagnostic arteriograms are possible using carbon dioxide as the contrast agent.
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PMID:Carbon dioxide digital subtraction arteriography: a pilot study. 212 Dec 15

We investigated the incidence of silent myocardial ischemia and infarction as assessed by dipyridamole thallium scintigraphy in 30 diabetic patients with peripheral vascular disease and without clinical suspicion of coronary artery disease. Seventeen patients (57%) had thallium abnormalities, with reversible thallium defects compatible with ischemia in 14 patients (47%) and evidence of prior, clinically silent myocardial infarction in 11 patients (37%). Thallium abnormalities were most frequent in patients with concomitant hypertension and cigarette smoking (p = 0.001). These results suggest that unsuspected coronary artery disease is common in this particular group of patients with diabetes mellitus.
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PMID:Silent myocardial ischemia and infarction in diabetics with peripheral vascular disease: assessment by dipyridamole thallium-201 scintigraphy. 223 59

The use of microvascular tissue transfer as an adjunct to arterial reconstruction has begun to have a positive impact on limb salvage in patients with advanced arteriosclerosis and nonhealing ischemic wounds. However, many patients with severe peripheral vascular insufficiency not amenable to conventional arterial reconstructive procedures eventually require limb amputation. We have treated 12 patients with advanced peripheral vascular disease and nonhealing ischemic wounds by three different methods. These included distal bypass alone, distal bypass done in conjunction with free-tissue transfer, and free-tissue transfer alone. All bypass grafts were done to vessels at or below the ankle using a reversed saphenous vein. In each case, the distal anastomosis was performed, using the operating microscope and standard microvascular technique. Mean follow-up for these patients is 18 months. Distal bypass alone resulted in limb salvage in three of five patients. In the combined bypass and free-flap group, three of five patients had salvage of their threatened extremity at a 1-year follow-up. Two patients with ischemic ulcers, rest pain, and unsuitable distal vessels for bypass were treated with free-tissue transfer alone. This resulted in healed wounds, limb salvage, and complete resolution of the rest pain symptoms in both patients. When advanced ischemia is complicated by large areas of tissue loss, combined bypass and microvascular free-issue transfer, performed in stages or simultaneously, is safe and can often result in limb salvage. In the rare instance of a completely obliterated distal runoff bed, free-tissue transfer alone may provide not only a healed wound, but also a means of "indirect" revascularization of the extremity and limb salvage.
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PMID:Expanding the horizons in treatment of severe peripheral vascular disease using microsurgical techniques. 230 92

Previous reports of emergency coronary artery bypass grafting often included cases that were not true surgical emergencies, thereby creating inappropriately favorable results. To accurately investigate this important subgroup of patients, we analyzed our recent experience with truly emergent coronary artery bypass grafting. From January 1984 to January 1989, 117 patients underwent true emergency bypass grafting for acute refractory coronary artery ischemia. Clinical deterioration was associated with failure of percutaneous angioplasty in 37 patients and instability during diagnostic catheterization in 13 patients. Refractory ischemia developed in the remaining patients while on the ward or in the intensive care unit. All operations were performed within four hours of surgical consultation, most within one hour. Overall in-hospital operative mortality was 14.5% (17/117), and 76.5% of deaths (13/17) were due to cardiac-related causes. Major morbidity occurred in 35.9% (42/117). Univariate analysis isolated ejection fraction, extent of coronary artery disease, previous myocardial infarction, hypertension, need for inotropic support, use of an intraaortic balloon pump, and cardiopulmonary resuscitation as risk factors for operative mortality. Stepwise multivariate analysis confirmed that previous myocardial infarction, hypertension, cardiopulmonary resuscitation, and reoperation were independently significant risk factors. Age, sex, diabetes, left main disease, and peripheral vascular disease had no significant impact on the prognosis. The 4% operative mortality (2/50) for patients taken directly to the operating room from the catheterization suite was significantly lower than the 22.4% mortality (15/67) associated with emergencies arising on the ward or intensive care unit (p less than 0.01). A logistic risk equation developed from this population accurately modeled operative mortality.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:True emergency coronary artery bypass surgery. 232 56

Platelet activation releases thromboxane A2 and serotonin, which acts on blood vessels through a specific, 5-hydroxytryptamine (5-HT2) receptor. The development of ketanserin, the selective 5HT2 receptor blocker, has made it possible to explore the role of serotonin in patients with advanced atherosclerotic disease. Ketanserin in low doses (3 to 30 micrograms/kg) was administered intra-arterially to 23 patients with symptomatic peripheral occlusive vascular disease during peripheral angiography: an additional seven patients received a placebo. The angiographic response was evaluated by coded reading and by computer-assisted measurement of arterial segments in four anatomical regions (pelvis, thigh, knee, and lower leg). Hemodynamic changes were assessed by mercury strain gauge plethysmography and Doppler pressure measurement. Unequivocal vasodilatation was observed in zero of seven placebo-treated patients and in 13 of 23 (57%) treated patients primarily at the level of collateral vessels. Dilation of the geniculate arteries, a major source of collaterals to the calf, was associated with a significant increase in the blood flow delivery to the calf. There was a moderate drop of systemic blood pressure in patients who failed to respond with peripheral vasodilatation. Ketanserin induces hemodynamically significant vasodilatation in some patients with peripheral vascular disease, suggesting that serotonin may contribute to ischemia in some patients with advanced atherosclerosis.
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PMID:Atherosclerosis, peripheral arterial disease and the vascular response to ketanserin. 234 79

Patients with renal failure and underlying peripheral vascular disease pose a difficult management problem in establishing long-term angioaccess for chronic hemodialysis. This report summarizes our experience with five debilitated patients who developed acute upper extremity ischemia after forearm fistula construction corrected by fistula ligation. Successful angioaccess was achieved without ischemia recurrence by construction of proximal bridge fistulae with arterial inflow based on branch arteries of the axillary artery. The relatively small size of the branch vessel was the main factor in limiting fistula flow while permitting normal distal axillary artery flow. In four patients direct fistula flow measurements ranged from 200 mL per minute to 620 mL per minute. Axillary arterial flow distal to the fistula ranged from 120 to 200 mL per minute and did not significantly change after fistula construction or during temporary occlusion of the fistula. Four of the five patients continue to dialyze uneventfully from 4 to 8.5 months. One patient died after discontinuation of dialysis 1 month after operation.
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PMID:Vascular access in patients with arterial insufficiency. Construction of proximal bridge fistulae based on inflow from axillary branch arteries. 237 49

In keeping with the recent emphasis on smoking and health, we conducted a survey of patients with peripheral vascular disease in our institution. The objective of the survey was to examine the patient's perspective on a) the relative contribution of smoking to his disease, b) the value of alternative measures to encourage smoking cessation, and c) the smoker's role and responsibility in payment for future health care. One hundred sixty patients at the VAMC in Palo Alto, California, participated in the study. The participants were men who had visited the clinic with complaints related to vascular insufficiency. The "typical" smoker from our survey a) had smoked for more than 30 years, b) acknowledges the association between smoking and disease, and c) will not stop smoking until serious health problems intervene. The majority of respondents expected the same health care regardless of smoking history and did not endorse paying more for health services. Most patients identified serious heart and lung disease as potential sequelae of cigarette smoking, however only 44 per cent of active smokers attributed their peripheral vascular disease to smoking. Although the survey was conducted on patients with complaints related to vascular insufficiency, few respondents identified an association in smoking with gangrene of the lower extremity or leg amputations. It is unclear whether this represents a failure on the part of health professionals to stress this relationship or denial on the part of the smoker. Physicians should continue to advise against cigarette smoking. A strong relationship between continued smoking and lower extremity ischemia or amputation needs to be emphasized in the clinical setting and through public health information campaigns.
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PMID:Patient perspectives on smoking and peripheral vascular disease. A veteran population survey. 239 93

One hundred ninety-five patients have been evaluated for possible laser recanalization (LR). Current laser delivery systems are most appropriate for the treatment of superficial femoral, popliteal, or isolated common iliac artery occlusions, and therefore one half (110) of the patients were initially excluded because of inappropriate disease location. An additional 39 patients were excluded because they showed minimal symptoms or the procedure would have been excessively risky for them. The remaining 46 patients underwent LR for total arterial occlusions, with relief of symptoms and increased ankle brachial indexes in 22 (48%). Of the four patients who could not be surgically reconstructed because of tibial artery occlusion, none was successfully treated. Only one patient required emergency reconstruction for ischemia after LR failure, and no procedures were required for treatment of perforation or bleeding. Successful LR was most likely when isolated lesions less than 15 cm in length, in the common iliac, middle or distal superficial femoral, and above-knee popliteal arteries were treated. Of the 22 patients for whom LR was successful, 11 would have been candidates for standard surgical therapy, six would have been excluded from such therapy by medical or surgical risks, and five had symptoms usually considered too mild to be offered surgery. Thus, at present the impact of LR on the treatment of patients with peripheral vascular disease appears limited.
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PMID:Initial results of laser recanalization in lower extremity arterial reconstruction. 252 63


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