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Query: UMLS:C0030193 (pain)
 261,466 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

In a subset of patients requiring lower extremity revascularization, the popliteal artery may be used for inflow, thereby minimizing dissection and the length of vein required for bypass. This retrospective study was done to define the risks and benefits of arterial reconstruction in a population of patients having popliteal-to-distal bypass procedures. Between 1986 and 1990, 32 surgical procedures were performed on 29 patients. The patient's ages ranged from 46 to 86 years, with a mean age of 68 years. Twenty-four of 29 (83%) were men and 19 of the 29 (66%) had diabetes. Most patients had multiple indications for surgical intervention, and these included rest pain (54%), nonhealing ulcers (64%), and gangrene (29%). Arterial bypass with use of the popliteal artery for the proximal anastomosis was performed with in situ saphenous vein (50%), reversed saphenous vein (41%), and orthograde autologous vein (9%). Distal anastomoses were to the posterior tibial artery in 11 bypasses (33%), the peroneal artery in 10 (30%), the anterior tibial artery in two (6%), and the dorsal pedal artery in 10 (30%). Two deaths occurred in the perioperative period for an operative mortality rate of 6.9%. With use of life-table analysis, the cumulative graft patency rate was 97% at 1 year, 97% at 2 years, and 63.5% at 4 years. The overall cumulative limb salvage rate was 90.1% at 1 year, 90.1% at 2 years, and 78.8% at 4 years.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Popliteal-to-distal bypass for limb-threatening ischemia. 157 30

When sufficient vein for a completely autogenous femorotibial artery bypass is not available, composite sequential grafting by using vein combined with polytetrafluoroethylene material is a surgical option. This study reviews what is currently the largest collection of these grafts and focuses on technical aspects and long-term patency characteristics. During a 7-year period 67 composite sequential bypasses were used to manage rest pain (38), ulcer (18), or gangrene (11) in 62 patients (mean age, 66 years). Fifty-two percent were men, and 51% had diabetes. This method was used as a primary reconstruction in 30, a second bypass in 16, and in 21 it was used after multiple other failed bypasses. Femoral to above-knee popliteal (44) and below-knee popliteal (23) 6 mm polytetrafluoroethylene grafts were placed. Then extensions of greater saphenous (57) or lesser saphenous (10) vein were anastomosed to the anterior tibial (19), posterior tibial (26), or peroneal (22) arteries. Fifty-three percent were maintained on long-term warfarin (Coumadin) anticoagulation, and 33% were maintained on aspirin. No deaths occurred in the perioperative period. Bypass patency was ascertained by a Doppler pressure and waveform analysis, with mean follow-up of patency or to the time of graft failure of 33 months (1 to 91 months). Three-year patient survival was 72%. Cumulative life-table primary patency of 72% (1-year), 64% (2-year), and 48% (3-year) was calculated. Two grafts are functioning 7 years after placement. Limb salvage was 84% at 2 years and 70% at 4 years. At the time of failure, five grafts retained a patent venous bypass segment, which allowed prompt reconstruction of the proximal portion. In a comparison of grafts with early failure and those with long-term patency, the SVS/ISCVS runoff score, vein diameter, tibial artery diameter, and coagulation status were similar. However, patients with the popliteal anastomosis above the knee had 2-year patency of 72% compared with 46% for those with below-knee anastomoses. This technique, when possible, appears preferable to an all prosthetic tibial bypass.
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PMID:Long-term evaluation of composite sequential bypass for limb-threatening ischemia. 143 71

Wound complications after in situ saphenous vein bypass occur frequently, lengthen hospitalization, and threaten graft viability. From May 1981 to March 1991, 117 consecutive male patients underwent 126 in situ operations: 45 (36%) femoropopliteal, 75 (59%) femorotibial, and 6 (5%) grafts to the dorsal pedal artery for gangrene or ulcer (n = 69), rest pain (n = 54), or claudication (n = 3). Wound complications developed in 55 grafts (44%): erythema developed in 11, but they healed primarily, 19 had skin edge necrosis or localized lymph leaks, 12 had necrosis or infection into the subcutaneous tissue without danger to the graft, and invasive infections that threatened the graft developed in 13. Risk factors for a subsequent wound infection included the development of a lymph leak (p less than or equal to 0.05) and early postoperative graft revision for thrombosis, wound hematoma, retained valve or arteriovenous fistula (p less than or equal to 0.05). The mean time to appearance of a graft-threatening wound infection was 31 days, and 10 of 13 were located in the distal limb. Twelve of the 13 deep infections required operative debridement, and seven required a flap or split thickness skin graft for coverage. Gram-negative as well as gram-positive infections responded equally well. No grafts were lost, and no deaths occurred. Despite the high incidence of wound complications, an aggressive therapy regimen permitted universal graft salvage.
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PMID:Wound complications of the in situ saphenous vein bypass technique. 157 40

Exercise-induced exertional compartment syndrome was first described by Vogt in 1945 as "march gangrene." The authors report a case of a 20-year-old United States Marine presenting with the florid findings of acute crural compartment syndrome. The patient's history of prior episodes of crural pain following long hikes led the authors to conclude that this patient had a chronic exertional compartment syndrome.
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PMID:Exertional compartment syndrome in a Marine grunt. 147 Mar 65

Atherosclerotic occlusion of the entire infrarenal abdominal aorta can produce gangrene, rest pain or claudication and can progress to involve the renal artery origins. Features of the operative technique for treating these juxtarenal aortic occlusions include self-retaining retraction, mobilization of the left renal vein with division of all non-renal branches, exposure of the suprarenal aorta and renal arteries by division between clamps of the surrounding paraaortic fibroareolar tissue and fat, sharp division of crural attachments to the aorta, control of the two renal arteries with doubled vessel loops and then direct vertical clamping of the suprarenal aorta. Through an arteriotomy below the renal arteries, 2-4 cm of pararenal aorta are cleared of thrombus and atherosclerotic debris under direct vision. After transfer of the suprarenal clamp to an infrarenal position, conventional aortobifemoral bypass is then performed. In a series of 18 patients with juxtarenal aortic occlusion managed by this technique, suprarenal clamp time ranged from 4 to 25 minutes (mean, 13 minutes). There was no morbidity from renal failure or emboli and no mortality. This technique allows for deliberate, careful disobliteration of the pararenal and infrarenal aorta and minimizes the risk of renal embolization.
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PMID:Management of juxtarenal aortic occlusions: technique for suprarenal clamp placement. 161 Jun 65

Aortic saddle embolus is a rare but serious form of arterial embolisation in patients with myocardial infarction. Four patients with aortic saddle embolism with peripheral propagation of the clott are reported. Two patients had suffered an attack of acute anterior myocardial infarction (one and four weeks respectively) prior to the embolic episode. One patient had a transmural myocardial infarct five years ago, and the 4th patient had dilated cardiomyopathy. The onset was sudden, marked by pain, parasthesias, pallor, pulselessness in three patients, and gradual in one. Two of the three patients (both females) in whom clott migration occured in only one limb developed below-knee gangrene of the affected side. In one patient (a young male) clott migration occurred in both popliteal arteries and the limbs were spared from developing gangrene although he continues to have leg angina. One patient presented with intermittent calf claudication only. All our patients reported late due to which none could be subjected to embolectomy.
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PMID:Saddle embolism of aorta. 162 21

A number of patients (151) with ischaemia of the lower limb presenting as ulcers or gangrene and/or rest pain were entered into a multicentre randomised double-blind controlled study of intravenous iloprost or placebo given for 14-28 days. Patients were assessed for evidence of ulcer healing as judged by reduction in size with granulation at the base and relief of rest pain sufficient for discharge from hospital. Based on these criteria, 45% in the iloprost and 29% in the placebo group showed evidence of improvement of clinical status at the end of treatment (p less than 0.05). At 6 months follow-up improvement was maintained in 42% of iloprost patients and 26% of placebo patients (p less than 0.01). At this follow up 64% of the iloprost patients and 42% of the placebo patients were alive with a viable limb. Thirty-one per cent of the iloprost patients and 47% of the placebo patients underwent major amputation (p less than 0.05). It has been shown that iloprost significantly improves patients with ischaemic ulcers or gangrene compared with placebo. This improvement is maintained for up to 6 months after treatment resulting in a reduced major amputation rate.
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PMID:Treatment of limb threatening ischaemia with intravenous iloprost: a randomised double-blind placebo controlled study. U.K. Severe Limb Ischaemia Study Group. 172 Apr 3

Recent reports have documented excellent results for inframalleolar reconstructions. We reviewed our outcomes for dorsalis pedis bypass and report a more modest rate of success. We analyzed reasons for failure. Sixty-nine patients underwent 73 dorsalis pedis bypass procedures between 1984 and 1991. Seventy-eight percent of the patients were diabetics. Inflow was from the external iliac in 1, femoral in 35, popliteal in 34, and tibial in 3. The operative indication was gangrene in 57%, ulcer in 22%, and rest pain in 21%. Forty-six percent of limbs had foot infection, with six requiring minor amputation before the bypass and 24 requiring minor amputation after bypass. There was one perioperative death. Twenty-nine grafts failed over the course of the series. The primary patency rate at 2 years was 59.2%. The limb salvage rate was 73.5%. Of the 10 perioperative failures, four were due to continued foot infection, four to marginal vein quality, and two to skin necrosis of the bypass incisions. Graft failure occurred at 3 to 30 months in 10 of 14 patients who had deficient anterior arches, with segmental occlusion of the dorsalis pedis or its branches. Six of the 14 patients with extensive infections of the forefoot or extensive heel ulcers required amputation with patent bypasses. In dorsalis pedis bypass, failure to achieve limb salvage was more likely in patients with marginal vein quality, deficient anterior pedal arches, and extensive foot infection. In patients where the chance of failure appears to be unacceptably high, primary amputation should be considered.
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PMID:The dorsalis pedis bypass--moderate success in difficult situations. 173 2

Between January 1985 and January 1989, 13 patients underwent femorotibial bypass using a polytetrafluoroethylene graft with a remote distal arteriovenous fistula. Indications for operation were gangrene in six patients, rest pain in five patients, and nonhealing ulcer in two patients. No patient had a usable autogenous saphenous vein. Eight patients had a previous failed femorodistal bypass. Standard femorotibial bypass was performed using a 6 mm thin-walled polytetrafluoroethylene graft. The distal remote arteriovenous fistula was done on the same artery. Warfarin was given postoperatively. Graft patency was assessed by duplex scan and digital arteriography. There was no postoperative mortality. All grafts and fistulas remained patent initially with improvement in symptoms and limb salvage. In the follow-up period there was continued graft patency in all but two patients who had a below-knee amputation. Three patients died with a patent graft. In two additional patients the graft remained patent but the fistula closed. We believe that in selected situations, the remote distal arteriovenous fistula is a potentially valuable adjunct for obligatory polytetrafluoroethylene femorotibial bypass.
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PMID:Remote arteriovenous fistula with infrapopliteal polytetrafluoroethylene bypass for critical ischemia. 177 58

In this study we investigated the efficacy of percutaneous transluminal angioplasty (PTA) and laser percutaneous transluminal angioplasty (LPTA) as an adjunct to surgery in patients with peripheral vascular disease. We report 84 cases of the simultaneous association of direct arterial surgery and angioradiological procedures to treat 82 patients with arterial occlusive disease of the lower limbs. Sixty-five patients (79.2%) were affected by severe claudication and 14 (19.6%) presented with rest pain or gangrene. One patient (1.2%) had signs of acute ischemia. PTA or LPTA were utilized as an inflow procedure in 41 cases (48.8%), as an outflow procedure in 24 (28.6%) and in 19 cases (22.6%) to recanalize an arterial occlusion in the contralateral limb opposite to surgical interventions. Immediate postoperative patency was achieved in 79 cases (94.0%), while in 5 cases (6.0%) it was impossible to perform a satisfactory balloon dilatation. The complication rate was 16.6%: 10 perioperative thromboses, 1 plaque dissection, 1 peripheral embolus, 1 haemorrhage and 1 femoral nerve lesion. No perioperative mortality occurred in this group of patients. Long term patency, analyzed with the life-table method (mean follow-up: 28 months) was respectively 78.0%, 76.3% and 78.9% at 5 years. These data indicate that the combined revascularization technique should always be recommended in properly selected patients because it is less invasive, the surgical risk and operative time are reduced and associated with early and long term cumulative patency rates comparable to those of extensive surgery.
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PMID:PTA and laser assisted PTA combined with simultaneous surgical revascularization. 183 Aug 82


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