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

A series of 62 femorofemoral bypass grafts (FFBG) is reported. The indication for this operation was unilateral iliofemoral occlusion with severe ischemia of the lower limb in poor-risk patients. Severe ischemia presented as rest pain and/or minor necrotic lesions to the foot fingers, while patients were defined poor-risk for aging and concomitant diseases advising major surgical procedures and general anaesthesia. Claudication was not considered as an indication for this operation, and this statement is discussed in detail reviewing the literature. Operative death rate was approximately 6.4% (4 subjects), due to acute renal failure, revascularization syndrome, cardiac arrest and pulmonary oedema. Twenty subjects had had a total of 33 previous vascular reconstructive procedures; this occurrence did not reveal any statistically significant consequences on long-term patency rate, although a difference was seen in favour of the patients who had not undergone previous vascular reconstructive procedures. In the group of patients who underwent FFBG as the first vascular procedure, five early occlusions occurred: three Fogarty catheter thrombectomies were successful. Cumulative patency rate was then 77% at 36 months in the series of 58 survivors. Rest pain was relieved in any instances and a satisfactory improvement of claudication was obtained.
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PMID:The femorofemoral bypass graft. Report of a 11-year experience. 225 Sep 77

Since 1971 175 femoro-crural bypasses were performed. Rest pain and gangrene were present in 90% of the cases; 28% had undergone previous surgery for ischemia of the same limb. The autogenous saphenous vein was the first choice and could be used in 81% of cases. Prosthetic material consisted consecutively of the regular PTFE (N = 12), the Dardik biograft (N = 13) and the thin-walled reinforced PTFE (N = 7). One dacron prosthesis was used. The two-year patency (Life-table) for the prostheses was 18%. Results of the composite grafts were as poor as those of complete prosthetic grafts. Saphenous vein grafts had a two-year patency of 70% and a five-year patency of 59%. Veno-venous anastomoses had no adverse influence on patency. Exploration of both legs for acceptable parts of the saphenous vein is indicated before the use of prosthetic material is justified.
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PMID:Results of prosthetic grafts in femoro-crural bypass operations as compared to autogenous saphenous vein grafts. 294 65

In the elderly, arterial disease may not necessarily require operative intervention if the patient is not functionally disabled or can adjust to self-imposed limitations. However, with nonhealing skin lesions, gangrene, impending limb loss, or ischemic rest pain, reconstructive arterial surgery must be considered. Pain at rest signals advanced limb-threatening ischemia. The pattern of pain distribution over the foot distinguishes it from common nighttime leg cramps.
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PMID:Peripheral vascular disease: treatment and referral of the elderly. Part I. 388 86

Clinical experience with aortic saddle embolus (ASE) is not extensive due to the relative infrequent lodging of emboli at the aortic bifurcation. During the period 1962-1982, 26 patients (mean age, 56 years) were treated at the UCLA Medical Center for ASE and followed from 2 to 158 months (mean, 45 months). These cases were reviewed in order to identify features of diagnosis, anticoagulation, and operation which impact on results. All 26 patients presented with bilateral lower extremity ischemia with or without extension of clot to the iliac bifurcation. Ninety-six per cent of emboli were of cardiac origin and one-third occurred in patients who had previous symptoms of chronic lower extremity ischemia. Rest pain and motor/sensory deficits were main complaints in 92% of the patients, but did not become manifest until more than 6 hours, unlike more distal emboli which have an earlier presentation. Preoperative angiography, even in the patient with a history of claudication, has a small role in planning the surgical approach to patients with ASE and, although performed in 11 patients, it influenced operation in only two. Operation within the "golden period" of 6 hours after embolization did not significantly influence outcome after ASE, since 20 patients were operated on more than 6 hours after embolization, with results similar to six patients who were operated on less than 6 hours after embolization. Early high-dose heparinization, used in all patients and maintained for a mean of 12 days, may have contributed to this effect. In 22 patients (85%) Forgarty catheter extraction via bilateral groin approaches was used with a mortality of 14%; only one death was directly attributed to the catheter embolectomy. In 15% of patients, a direct approach on the aorta was selected with a zero mortality rate. Postoperative functional result was excellent with an amputation rate of only 2% (one limb). Re-embolization occurred in seven patients (27%) after discharge, five of whom had not been maintained on Coumadin and two who were not anticoagulated adequately. The authors conclude that the keys to successful treatment of ASE include high dose heparin which is maintained through the perioperative period, embolectomy without preoperative angiography, and maintenance of long-term oral anticoagulation.
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PMID:Aortic saddle embolus. A twenty-year experience. 685 79

The authors' experience with 46 patients treated over 8.5 years was reviewed to determine the optimal secondary revascularization procedure after occlusion of a unilateral aortobifemoral graft limb. A total of 64 procedures was performed on these patients to restore and maintain graft patency. Repetitive operations for reocclusion were needed in 14 patients (30%). Transcatheter thrombolytic therapy was used in 14 patients, four as sole therapy and 10 in conjunction with operation. The mean time from aortofemoral grafting to presentation with graft limb occlusion was 59.4 months. Rest pain or severe ischemia was present in 85%, and severe claudication in the remainder. Some 78% had urgent operation after diagnostic angiography and catheter-directed thrombolytic therapy was attempted in 22%. The etiology of graft thrombosis was outflow obstruction in 78.2% of cases. Inflow was obtained by surgical thrombectomy in 35 and by lytic therapy in 13. Extra-anatomic inflow was used in 11 and intra-abdominal thrombectomy or redo aortofemoral grafting in five. Outflow procedures, mainly profundaplasty, were performed in all but five cases (four urokinase and one surgical). Infrainguinal bypass was needed in 10 cases in addition to the groin reconstruction. Catheter-directed thrombolysis was successful in 13 of 14 instances; however, in nine of these residual stenosis was disclosed in the outflow requiring surgical repair. Ultimately, 12 of 14 cases treated with thrombolysis required surgical intervention. Cumulative patency for all procedures was 68%. Complications were seen in 14% of cases. Operative mortality was 5%, and limb salvage was obtained in 85%.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Aortofemoral graft occlusion: strategy and timing of reoperation. 765 41

The diagnosis of unstable angina encompasses a broad spectrum of patients with myocardial ischemia, varying widely in cause, prognosis and responsiveness to therapy. A new clinical classification of unstable angina is based on the following 2 components: severity, and the clinical setting in which unstable angina develops. The hypothesis that this clinical classification correlates with the underlying coronary artery anatomy was tested. In 238 consecutive patients, an unstable angina score ranging from 2 to 6 was determined by adding the scores for severity (1 = unstable angina without pain at rest; 2 = pain at rest > 48 hours before angiography; and 3 = pain at rest < or = 48 hours before angiographic evaluation) and the clinical setting of unstable angina (1 = unstable angina secondary to a noncardiac condition; 2 = primary unstable angina; and 3 = early postinfarction unstable angina). Fifty concurrently studied consecutive patients with stable angina were assigned a score of 0. Patients with unstable angina averaged 63 +/- 11 years of age, and 165 were men (69%). Pain at rest occurred in 202 of 238 patients (85%), and angiography was performed < or = 48 hours in 139 of these patients (69%). Among patients with unstable angina, 5 (2%) had secondary unstable angina, 143 (60%) had primary unstable angina, and 90 (38%) had postinfarction unstable angina. Multivariable regression analysis identified the unstable angina score as the most important predictor of intracoronary thrombus (p = 0.011) and lesion complexity (p = 0.004) in the ischemia-related artery.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Relation between clinical presentation and angiographic findings in unstable angina pectoris, and comparison with that in stable angina. 836 68

A total of 114 patients with critical lower limb ischemia from 11 hospitals were randomized to either Pentoxifylline 600 mg or placebo given intravenously twice a day. Rest pain was evaluated both by the investigator and the patient. Pain was evaluated with the patient in the supine as well as in the sitting position using a pain score scale, a pain relief scale and a visual analogue scale. All patients underwent a clinical examination, measurement of ankle systolic blood pressure and arteriography. These arteriograms were evaluated by a radiologist who did not know which treatment had been given. If no beneficial effect of the treatment was observed after one week, further medication was discontinued. Otherwise the treatment continued for two additional weeks. There was no statistically significant difference in pain-free or absolute walking distance between the two groups. Evaluating the patients with the most pronounced amelioration of rest pain in the supine position (divided by 4 to divided by 2 points), there was a beneficial effect of Pentoxifylline compared to placebo. Evaluation of the total material did not, however, show any statistical significances between the groups. From further subgroup analysis excluding patients who had only slight pain at the entrance of the study, there was a significant improvement in rest pain in favour of Pentoxifylline following seven days of treatment. In this group the pain evaluated according to this visual analogue scale had decreased 37 points (54%) compared to 14 points (25%) in the placebo group. More side effects, mainly gastrointestinal, were observed in the Pentoxifylline group. Most of these could be eliminated by increasing the infusion time. Further investigations are necessary to evaluated the place of Pentoxifylline in the treatment of patients with critical limb ischemia.
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PMID:Efficacy and clinical tolerance of parenteral pentoxifylline in the treatment of critical lower limb ischemia. A placebo controlled multicenter study. Norwegian Pentoxifylline Multicenter Trial Group. 873 41

Under analysis are the factors of operative risk and results of operative interventions on distal segments of the arteries in elderly and senile patients with critical ischemia of lower extremities against the background of generalized atherosclerosis. Seventy-eight bypasses were fulfilled: ileo-femoral, femoro-popliteal, femoro-tibial, femoro-fibular. Pain at rest and gangrene of the foot and toes tissue were considered to he indications to bypasses. Among the risk factors smoking and arterial hypertension are particularly stressed. Postoperative lethality in patients of 80 years of age and older was 12.5%, among the patients from 70 to 80 years of age--7.7%. The active strategy is believed by the authors to be justified for revascularization of the extremity distal segments in critical ischemia and threatening amputation in the patients of 80 years of age and older.
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PMID:[Distal shunting in critical ischemia of the lower extremities in patients younger and older than 80]. 923 66

Approximately 10% of people age >55 years have asymptomatic peripheral atherosclerotic disease (PAD), 5% have intermittent claudication (IC, the cardinal symptom), and 1% critical leg ischemia (rest pain or gangrene). In patients with IC, worsening occurs in approximately 16%, bypass surgery is required in approximately 7%, and amputation in approximately 4%. Disease progresses more frequently in diabetics and in tobacco smokers. Patients with PAD suffer increased cardiovascular morbidity related mainly to coronary artery disease with a mortality rate of approximately 30% after 5 years. Compared to patients without PAD, the relative risk of coronary death is approximately 6.6, overall cardiovascular mortality 5.9, and all-cause mortality 3.1. Pain at rest or ischemic gangrene indicates severe, often multilevel arterial occlusive disease and calls for aggressive management, which usually includes angiography and revascularization by percutaneous angioplasty or surgery. Critical limb ischemia results in some 150,000 amputations annually in the U.S., with perioperative mortality rates of 5-10% for below-knee and up to 50% for above-knee amputation because of comorbidities. Physical findings include trophic signs of ischemia, vascular bruits and peripheral pulse deficits. Ischemic ulcers usually involve the tips of the toes or the heel of the foot, and are typically painful on elevation and most bothersome at night. Ancillary diagnostic modalities begin with the ankle/arm systolic pressure index (ABI); a value <0.90 indicates PAD with significant prognostic implications. More precise assessment in the noninvasive vascular laboratory may involve a combination of segmental limb pressure measurements and pulse volume waveform recording, which is over 90% accurate for predicting the level and extent of PAD. Exercise testing enhances the value of these observations. Magnetic resonance imaging methods are emerging to characterize the arterial wall and atherosclerotic lesions. The diagnosis of PAD does not generally require invasive techniques, and most patients with IC do not need contrast angiography. Angiography is indicated for mapping of the extent and location of arterial pathology prior to revascularization.
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PMID:Evaluation of patients with peripheral vascular disease. 1235 43

We sought to investigate the safety and efficacy of intramuscular gene therapy with vascular endothelial growth factor (VEGF) in patients with chronic critical leg ischemia.Gene transfer was performed in 24 limbs of 21 patients with rest pain, some of whom also had nonhealing ischemic ulcers (n = 16) due to occlusive peripheral arterial disease. Between 400 microg and 2000 microg of phVEGF(165) (400 microg, n = 2; 800 microg, n = 4; 1200 microg, n = 4; 1600 microg, n = 6; and 2000 microg, n = 8) was injected directly into the muscles of the ischemic limb; the same dose was injected 4 weeks later. The ratio of blood pressures at the ankle and brachial artery was measured before and after treatment. Mean (+/- SD) plasma levels of VEGF increased significantly from 26 +/- 31 pg/mL to 63 +/- 56 pg/mL (P <0.005), and the ankle-brachial index improved significantly from 0.58 +/- 0.24 to 0.72 +/- 0.28 (P <0.001). Magnetic resonance angiography showed qualitative evidence of improved distal flow in 19 limbs (79%). Ischemic ulcers healed or improved markedly in 12 limbs (75%). Rest pain was relieved or improved markedly in 20 limbs (83%). Amputation was performed in two limbs because of wound infection. Complications were limited to transient leg edema in six limbs. Intramuscular gene therapy with VEGF(165) for patients with chronic critical leg ischemia is safe, feasible, and effective.
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PMID:Intramuscular vascular endothelial growth factor gene therapy in patients with chronic critical leg ischemia. 1258 39


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