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Some patients with peripheral arterial disease may present with critical limb ischemia, a condition associated with high rates of morbidity and mortality. Early diagnosis and effective medical therapy and revascularization are indicated to avoid amputation and reduce mortality. Ideally, a multidisciplinary approach with collaboration between endovascular interventionist, vascular surgeons, podiatrist, infectious disease, and wound care specialist is recommended for these patients.

Our aim was to assess the long-term outcome for minor forefoot amputations. A retrospective study of 126 patients who had such amputations between 1999 and 2004 was performed. Patients were divided into 2 groups, diabetic (group A: 79 patients) and nondiabetic (group B: 47 patients). Angiograms were requested in 45 patients in group A compared with 31 patients in group B (P = ·77). In group A, 11 patients underwent further ipsilateral amputations compared with 30 patients in group B (P = ·02.). The 2 groups were equally likely to have vascular reconstruction (35% vs 37%). The overall 5-year mortality was 27%, with 58% of deaths occurring within the first year. This study shows that foot amputees have high mortality and reintervention rates. Adequate utilization of vascular services, extra vigilance in the prevention of complications, and risk factor modifications are required to improve postoperative outcomes.

Objective: This study was designed to describe the characteristics and clinical outcome of patients diagnosed with plantar vein thrombosis., Methods: Patients presenting with sudden pain and/or swelling of the foot were evaluated by duplex scanning of the affected leg. All the main foot veins were imaged with high resolution multi-linear array transducers. The location and extent of thrombosis was recorded in detail. All patients were scheduled for clinical and ultrasound follow-up within a week from the diagnosis and at various intervals thereafter., Results: Acute thrombosis was found in the plantar veins in 11 patients of whom 7 were females. Pain was presented in all patients, swelling in 8 and the left foot was involved in 7. From the risk factors evaluated, the most common were recent surgery 4, use of contraceptive pills 3, followed by malignancy, airplane travel, HIV-AIDS infection, and past history of DVT in one each. Plantar veins were exclusively affected in 8, with lower segment of the posterior tibial veins in 2 and the great saphenous vein in 1. In the follow up, there was evidence of thrombosis extension in 3 patients. At six months partial recanalization was found in 9 and complete in 2., Conclusions: Pain and swelling of the foot can be caused by plantar vein thrombosis. Complete or partial recanalization occurs in these patients by 6 months. Thrombi in the plantar veins can progress more proximally with the possibility of postthrombotic events.

Buerger's disease or obliterating thromboangiitis is an inflammatory pathologic condition affecting the distal vascular segments; it strikes young adults, especially males and heavy smokers. Medical and surgical treatment often fail to heal these patients, especially considering the frequent relapse of this disease linked with tobacco abuse--definitive healing often involves limb amputation. Electrical spinal cord stimulation is evaluated in this study with an analgesic aim and for improvement in skin microcirculation, with the goal of long-term healing of diseased limbs.

Thromboangiitis obliterans, or Buerger's disease, is a segmental occlusive inflammatory disorder of the arteries and veins most commonly affecting the lower extremities of young male cigarette smokers. The etiopathogenesis of the thromboangiitis obliterans is still obscure. The authors have identified heterozygosity for the recently described prothrombin gene 20210 G-->A variation and Factor V Arg 506 to Gln (Factor V Leiden) mutation in a patient with Buerger's disease. Both mutations confer a high risk of thrombosis. This coincidental observation may serve as further evidence that a thrombotic mechanism is involved in Buerger's disease.

The monoclonal immunoglobulin products of plasma cell neoplasm can give rise to a variety of manifestations including hyperviscosity, amyloidosis, cryoglobulinemia, neuropathy, and renal failure. A 50-year-old woman with monoclonal cryoglobulinemia developed extensive gangrene and ulceration of both hands and feet over several weeks requiring bilateral below-elbow and below-knee amputations. This case illustrates the importance of qualitative properties of paraprotein.

Objective: To evaluate in a group of seriously diseased patients with nonreconstructable chronic critical leg ischemia (CLI), treated by a combination of i.v. hydroxyethylrutosides (HR)* and oral anticoagulation (AC) by warfarin, the short-term effects on the cutaneous microvascular blood perfusion of the soles of feet and especially the long-term clinical outcome in terms of amputation and death., Design: A retrospective comparison between two groups of patients, HR + AC and a comparable reference group, fulfilling the same inclusion and exclusion criteria corresponding to the definition of CLI according to the Second European Consensus Document (1991). Clinical follow-up in both groups was made after 1, 3, 6, 12, and 24 months., Setting: Patients were examined at university departments of clinical physiology with special interest in peripheral vascular disease, in cooperation with colleagues at university departments of surgery, internal medicine and dermatology of Karolinska Hospital, Södersjukhuset and Huddinge Hospital., Patients: A total of seventy patients with CLI according to the definition of the Second European Consensus Document, 1991, ie, besides severe rest pain or ischemic lesions also a toe blood pressure < 30 mg Hg. Group with HR + anticoagulation (AC): 42 patients (19 diabetics, 23 nondiabetics). Reference group: 28 patients (18 diabetics, 10 nondiabetics). For distribution of age and toe blood pressure at baseline, see Table I., Interventions: Therapy group: besides ordinary standard therapy, daily HR infusions for a mean period of 3.6 weeks + oral anticoagulation continued to the end of the study at 24 months. A comparable reference group on the same basic therapy but without the combination HR + AC. PARAMETERS IN EVALUATION: Short-term parameters: clinical data, skin temperature, and fluorescein imaging. Long-term outcome: amputation or death., Results: Short-term and long-term results with HR + AC indicated that patients with severe CLI and very poor prognosis benefited in terms of survival and limb salvage from initial therapy with HR infusion combined with long-term oral anticoagulation. Results of this combined treatment seem at least comparable with those with i.v. prostacyclin analogies.

Venous aneurysms are rare lesions that may be the source of pulmonary emboli and can result in death. The authors have recently treated several patients who had venous aneurysms of the upper extremity, lower extremity, and jugular system. Venous aneurysms usually appear to have a safe natural history in these locations, although all of the reported patients required surgery after the development of symptoms owing to complaints of pain, and/or cosmetic appearance, and/or a diagnosis of thrombosis. These cases are presented, along with a review of venous aneurysms occurring at other sites and their causes.

Buflomedil hydrochloride (Buflomedil), a vasoactive drug, has been proven to improve pain-free walking distance in patients with peripheral arterial occlusive disease stage II of the lower extremities. In the present double-blind, randomized study, resting skin flux motion activity and skin flux response to a local heat stress at the hallux were assessed by laser Doppler fluxmetry (LDF) in claudicants. Twenty of 39 enrolled patients with severe intermittent claudication received a daily intravenous dose of 400 mg Buflomedil, and the other 19 patients received 0.9% NaCl as placebo over a 5-day period. Before treatment mean LDF skin resting flux, flux frequency, and flux amplitude were 2 +/- 0.8 Arbitrary Units (AU), 8.4 +/- 0.5 cycles per minute (c/min), and 0.12 +/- 0.01 AU, respectively in the Buflomedil group, and 2.3 +/- 0.3 AU, 8.7 +/- 0.7 c/min, and 0.13 +/- 0.02 AU in the placebo group (NS). Also the response to heat stress was identical in both groups: a slow initial increase of skin flux, followed by a reflex reduction, with a maximal initial flux increase to 138 +/- 12% of the resting value in the Buflomedil group, and 155 +/- 16% in the placebo group (NS). After 5 days of treatment the mean LDF skin resting flux, flux frequency, and flux amplitude were unchanged in both patient groups. The response to heating on the contrary was dramatically enhanced in the Buflomedil group (226 +/- 33%), against that in the placebo group, which remained unchanged (144 +/- 13%) after 3 minutes (P < 0.05), while after reflex reduction the flux in the Buflomedil group remained stable at 200% of resting value during further heating and was only approximately 140% in the placebo group (P < 0.05). It is concluded that Buflomedil, administered in a daily intravenous dose of 400 mg, does not alter the mean LDF skin flux and flux motion at the hallux in claudicants in resting conditions. Local skin heating on the contrary provokes a significant LDF-monitored skin flux increase, suggesting an improved capacity of cutaneous microvessel perfusion in stressed conditions.

Objective: To determine the clinical effectiveness of the end-diastolic pneumatic compression boot and of local antibiotics in treating limb lesions associated with diabetes and peripheral arterial, venous, and neuropathic disease., Research Design and Methods: Office and hospital data were kept over 15 years on 2177 episodes of leg problems classified by the Wagner method for 1514 legs of 1035 patients largely referred because of failure of standard therapies. The fate of the untreated legs served as a controls when possible., Results: Healing or improvement of treated legs was seen above that in the literature in all Wagner categories and was significant (P < 0.001) compared to the "control" leg, which deteriorated in 38.7% of patients. Significant risk factors against a successful outcome included smoking, inability to walk, increased home distance from the boot center, loss to treatment, hemodialysis, a Wagner 4-5 classification, inoperable iliac occlusions, vascular procedures before or after referral for boot therapy, and an aggressive vascular surgeon. Neuropathy allowed successful treatment of lesions nondiabetic patients could not tolerate. Relapse was significantly more frequent in arteriosclerosis obliterans (ASO) patients with diabetes than without diabetes and in patients with neuropathy than in those with ASO. Diabetes did not affect the relapse rate in stasis disease. The overall percentage of legs having major amputations was low: 2.5% for diabetic legs at the initial treatment episode, 1.6% at the time of a relapse, and 4.1% after seeking treatment elsewhere. For nondiabetic patients, the respective risks were similar: 2.0%, 1.2%, and 2.9%.

The effects of immersion of the lower leg and foot in fresh water and in carbon dioxide (CO2)-enriched water (1200 mg CO2 per kg water; succinate+sodium bicarbonate: Actibath, KAO Tokyo) on cutaneous circulation, vasomotion and oxygen tension (PO2) were measured by laser Doppler flowmetry and transcutaneous oximetry. On the first of two consecutive days patients were randomly assigned to have the lower extremities immersed in either fresh water or CO2-enriched water under standardized conditions (temperature, 34 degrees C; depth, 35 cm; immersion time, twenty minutes) with concurrent measurement. On the second day patients were switched to the other bath type. For both sets of measurements probes were attached symmetrically to the dorsum of each foot. Included in the study were 18 patients with mild, bilateral, peripheral, occlusive arterial disease (intermittent claudication, femoral or iliac type). During immersion in CO2-enriched water the Doppler laser signal and vasomotion amplitude rose by 300%, while PO2 increased by 10%. These increases were still apparent during the latter part of the measurement period, following withdrawal of the limbs from the bath, while patients were seated and supine. During immersion in fresh water and thereafter the Doppler laser signal was unchanged and the PO2 increase was considerably less marked. The authors were thus able to demonstrate vasodilation and increased oxygen utilization (Bohr effect) resulting from topical CO2 application, and hence, that the use of topical CO2 has an objective basis.

For many years, spinal cord stimulation (SCS) has been used successfully in various pain syndromes. SCS is also used to treat vascularly-impaired patients since it apparently improves the microcirculation. The exact physiological mechanisms involved are still unclear. There are even some anecdotal reports of a cooling of the legs during SCS. This study investigated the vascular effects of SCS in 15 patients with failed back surgery syndrome, using infrared thermography of the affected foot and capillaroscopy in the nailfold of the big toe. There were no statistically significant differences (Student's t test) in temperature (P = 0.923) or red blood cell velocity (P = 0.819 first day and P = 0.218 second day) in the affected foot with or without stimulation. A physiological difference in relation to neuropathic pain might explain the lack of improvement in skin microcirculation with SCS.

The strength of agreement between two noninvasive methods of assessing lower limb arterial disease and their relationship to patient symptoms following exercise have been investigated. Color-duplex ultrasound (CDU) and ankle/brachial pressure index (ABPI) (before and afer exercise) measurements were obtained from 200 consecutive patients referred to a vascular investigations laboratory. From these patients, 290 limbs were available for study, comprising limbs without previous vascular surgery, from patients without diabetes and who could attempt a walking exercise test. The overall level of agreement between CDU and resting ABPI measurements was 83% (Kappa 0.66). The ABPI technique identified the more serious disease; a resting ABPI of less than 0.6 gave 100% agreement with CDU. With higher resting ABPIs the level of agreement became poorer: 83% (0.6 < or = ABPI <0.9) and 76% (normal ABPI > or = 0.9). The addition of postexercise ABPI measurements in determining significant arterial disease increased the strength of relationship between the two techniques by only 2% (85%, Kappa 0.69). The exercise test was generally limited by the most symptomatic limb in each patient, and the agreement between CDU and postexercise ABPI measurements in these limbs was higher at 93% (Kappa 0.81). In comparison, agreement for the least symptomatic group of limbs was found to be poor (69%, Kappa 0.37). Compared with symptoms after exercise, overall agreements with CDU and ABPI were both 67% (Kappa 0.27). The agreement was better (91%) when the resting ABPI was less than 0.6. The ABPI is biased toward the detection of more severe disease and is more consistent with CDU when the most symptomatic limbs are compared. The relationship between either test and symptoms after exercise is strong only for limbs with major disease.

A seventy-four-year-old woman with arteriosclerosis obliterans, diabetes mellitus, and hypertension was admitted for the treatment of intermittent claudication and coldness and pain in the right lower extremity. After the administration of a vasopressin V1 antagonist, OPC21268, the symptoms were markedly improved. Furthermore, blood flow in the dorsalis pedis artery and the cutaneous temperature in the right foot increased in response to acute and chronic administration of OPC21268. OPC21268 may be a new useful therapeutic tool for the treatment of arteriosclerosis obliterans.

The authors describe a rare case of congenital afibrinogenemia with concomitant K-dependent protein C deficit that was brought to our observation for ischemic lesions of the foot in association with fibrinogen concentrate infusions. These lesions can be attributed to the association of various factors: fibrinogen infusion without heparin coverage, microtrauma, and protein C (PC) deficit. In fact, thromboembolic complications during afibrinogenemia were previously reported usually in association with substitutive therapy, and it is also known that PC deficit predisposes to thrombotic complications. The the authors' knowledge, the case described by them is the first in which PC deficit is associated with afibrinogenemia. This association cannot be explained by a common genetic mechanism because the genes for fibrinogen and for protein C are located on different chromosomes (chromosomes 4 and 2 respectively).

Pentoxifylline, a new trisubstituted methylxanthine derivative, is the most well known of a new group of hemorheologic agents. It has been shown to improve hemorheologic abnormalities associated with diabetes and atherosclerosis. The authors examined the role of pentoxifylline in the treatment of diabetic foot ulcers. Forty diabetic patients with foot ulcerations were included in the study, 20 of whom received conventional therapy and 20 received pentoxifylline (400 mg three times a day) in addition. Healing of ulcers after eight weeks of treatment was significantly higher in those on pentoxifylline, and the patients needed less mutilating surgery. Administration of pentoxifylline in addition to conventional therapy was significantly superior in the management of diabetic foot ulcers.

Some patients with chronic arterial obstruction of the limbs may still suffer the consequences of advanced tissue ischemia, including ulceration and rest pain, and face threatened limb loss in spite of available surgical, pharmacologic, and other treatments. Additional therapeutic modalities were thus sought to accomplish limb salvage. A literature review indicated that most reports on R-wave-triggered circumferential limb compression (cardiosynchronous limb compression [CSC]) demonstrate its ability to augment limb arterial blood flow and improve ischemic limbs. To determine the device's efficacy and safety, and possibly confirm earlier positive reports, a systematic study was undertaken, using older, as well as newer, more electronically reliable CSC devices. The present study was designed to determine the following: 1. objectively, by noninvasive vascular tests, changes in limb blood flow, if any, by CSC; 2. clinical effects of CSC, if any, on the ischemic limb; 3. duration of CSC-induced limb improvements, if any; 4. side effects or safety of CSC. The study demonstrated that CSC treatments: 1. caused increased limb blood flow as determined by increased ankle/arm indices and hallux photoplethysmograph waveform amplitudes during treatments; 2. led, in most cases, to improvement in or resolution of the presenting ischemic problem (eg, ulcer, cellulitis, rest pain); 3. induced limb improvements that persist for up to seven years 4. caused no adverse side effects.

The most characteristic pathophysiologic change in Buerger's disease or thromboangiitis obliterans (TAO) is considered the breakdown of microcirculation in the extremity, but this has not yet been proven. The purpose of this study is to examine the damage of microcirculation in TAO objectively, by means of intra-arterial injection of two kinds of radioisotope. In 7 TAO and 4 infrainguinal arteriosclerosis obliterans (ASO) patients, thallium 201 chloride (201Tl) and 99mTc macroaggregated human serum albumin (99mTc-MAA) were administered through bilateral common femoral artery injections. In the planar image of the foot, rectangular regions of interest (ROIs) were placed on the foot muscles and toes. Normalized counts of 99mTc-MAA in each ROI were divided by that of 201Tl, and the result was defined as the microcirculation damage index, based on their different kinetics. The damage index of the foot muscle was not different between ASO and TAO, but that of the toe was lower in TAO than ASO patients. Lumbar sympathectomy was performed in 5 TAO patients, but it did not improve the damage index. It is concluded that there is breakdown of the microvascular defense system from the beginning of the disease, and critical ischemia make the regional cell function deteriorate as if a precursor to a trophic lesion. Lumbar sympathectomy did not immediately improve microcirculation.

One of the major complications of diabetes mellitus is the occurrence of diabetic foot infection. The polymicrobial nature of diabetic foot infection has been well documented in the literature. In order to avoid amputation of the tissue affected, the ulceration and infection must be appropriately diagnosed and treated. This paper describes the microbiologic and clinical features obtained from 100 consecutive diabetic infected foot patients treated with either cefoxitin or ampicillin/sulbactam.

The transcutaneous pO2 (TCpO2) response following release of tourniquet cuff occlusion is expressed as oxygen reappearance time (ORT) and oxygen recovery index (ORI). In the present study the effects of blood perfusion and tissue oxygenation on ORT and ORI in healthy control subjects and two patient groups with peripheral arterial insufficiency were assessed. In control subjects, ORT reflects diffusion time for O2 molecules from capillaries to the TCpO2 sensor. In patients with claudication, ORT was prolonged probably because of delayed postischemic reperfusion and reduced tissue oxygenation. In patients with critical ischemia, prolonged ORT seems to be attributed more to reduced tissue oxygenation than to delayed postischemic reperfusion. ORI in control subjects and patients with claudication apparently depends more on capillary pO2 than on magnitude and duration of the postischemic reperfusion. In patients with critical ischemia, ORI is more related to decreased O2 delivery subsequent to reduced or absent reactive hyperemia response. In addition, increased O2 extraction ("O2 steal") and extensive countercurrent O2 exchange during low flow states may reduce ORT and ORI in severely ischemic skin.

Resting skin blood flow and the venoarteriolar response (VAR) were studied in 40 patients with diabetic microangiopathy and neuropathy, in 40 diabetics with microangiopathy, and in 30 normal subjects by means of laser-Doppler flowmetry. In patients with microangiopathy and neuropathy, resting flow (RF) was increased and the VAR was impaired to a greater extent than in patients without neuropathy. There was also a significant delay in the VAR in diabetics, particularly in patients with neuropathy. The microangiopathy index (VAR/RF) was on the average 71.3 in normal subjects, significantly lower (p less than 0.05) in diabetics without neuropathy (34.8), and even lower in those with neuropathy (13.6). The VAR was evaluated with different postural changes; The authors observed that in the passage from supine to standing the VAR is more evident. In conclusion these results confirm that the postural control of blood flow in the skin of the foot is impaired in diabetic microangiopathy, particularly in patients with neuropathy. The increased skin blood flow and the impaired VAR are causes of edema and may contribute to the thickening of capillary basement membranes observed in diabetes.

To determine whether foot transcutaneous oxygen tension (TcPO2) and ankle systolic blood pressure (SBP) measure similar aspects of peripheral vascular occlusive disease (PVOD), the authors examined their relationship at rest and following treadmill exercise. Thirty-seven PVOD patients (mean age 69.2 +/- 0.8 years) rested supine for twenty minutes, followed by a progressive treadmill walking test at a constant speed of 2 mph. The initial grade was 0%; this increased 2% every two minutes until maximal claudication pain (n = 19) or until the occurrence of such limiting symptoms as volitional fatigue (n = 6), ST segment depression (n = 4), dyspnea (n = 3), multiple premature ventricular contractions (n = 2), and angina (n = 2). Patients then rested supine for fifteen minutes. Foot TcPO2 was recorded before, during, and after exercise, whereas ankle SBP was measured before and after exercise. At rest, a curvilinear relationship was found between foot TcPO2 and ankle SBP (foot TcPO2 = 41.89 + 0.22(ankle SBP) + 0.0005 (ankle SBP2); SEE = 9.2, R = 0.64, R2 = 0.41, p less than 0.001). In contrast, the relationship was stronger and more linear during recovery, particularly at the sixth minute (foot TcPO2) = 8.33 + 0.35 (ankle SBP); SEE = 13.6, R = 0.86, R2 = 0.73, p less than 0.001). At rest, foot TcPO2 and ankle SBP characterized different aspects of PVOD because they shared only 41% common variance. During recovery, they provided similar information because up to 73% of the variance was shared. It is concluded that foot TcPO2 should also be used to assess PVOD patients because unique information is obtained at rest and values can be recorded during exercise.

Plugging of skin capillaries by activated white blood cells is one of the proposed mechanisms by which skin damage may be initiated in chronic venous insufficiency. The aim of this study was to determine whether a microcirculatory deficit was induced in the skin by raising the venous pressure proximally for thirty minutes. Seventeen subjects with no evidence of venous or arterial disease had laser Doppler velocimetry performed in the goiter region of the leg; 8 different subjects had the measurement done on the dorsum of the hand. Peak hyperemic response following three minutes of ischemia was measured before and after a thirty-minute period of sustained venous hypertension applied by a proximal tourniquet inflated to 80 mm Hg. A decrease in the peak flow: baseline flow ratio (median ratio 2.25 before, 1.70 after, p less than 0.02) and an increase in the time taken to reach maximal hyperemia (median time ten seconds before, twenty seconds after, p less than 0.01) were observed after the period of venous hypertension in the lower limb. The second parameter, but not the first, was significantly affected in the upper limb. The authors conclude that a microvascular deficit in the skin is demonstrable after a short period of venous hypertension. This is consistent with the white-cell-trapping theory, but other possible explanations are discussed.

The VSC (vacuum suction chamber) device, a new system to evaluate local capillary permeability, was used with laser Doppler flowmetry to study variations of permeability and of the microcirculation in 10 normal subjects; in 22 patients with moderate, superficial venous hypertension; and in 12 patients with postphlebitic limbs and severe venous hypertension. All these patients had distal (ankle and foot edema) in the evening. After a first assessment these subjects were studied again after two weeks without treatment and after two weeks' treatment with total triterpenic fraction of centella asiatica (TTFCA), tablets, 60 mg, tid. The VSC produces a wheal on the skin of the perimalleolar region that disappears (in average) in less than sixty minutes in normal subjects. The disappearance time (DT) is greater in conditions of increased capillary filtration and permeability. The three groups of subjects (normal and those with superficial and severe venous hypertension) had significantly different, increasing disappearance time of the wheals at the first observation. There were no significant changes after two weeks' observation, but after 2 weeks' treatment with TTFCA, there was a significant decrease of DT both in limbs with superficial and with deep venous incompetence. The improvement (decrease) of the abnormally increased capillary permeability was associated with a significant improvement of the microcirculation and symptoms (studied by an analogue scale line). In conclusion this study showed a combined improvement of the microcirculation and capillary permeability after treatment with TTFCA and the possibility of using the VSC to evaluate the effects of drugs (or other treatment) on local capillary permeability in patients with venous hypertension.

Transcutaneous oxygen and carbon dioxide tensions were measured during treadmill exercise in 30 patients with stages I and II arterial occlusive disease and 28 normal controls. Measuring sites were the dorsum of the foot and the frontal thorax. The calculated oxygen index at maximum exercise/rest (foot/thorax) differentiated with 100% sensitivity and specifity between the two groups. The oxygen index was the only parameter with a significant positive correlation with the pain-free walking distance, whereas, eg, oscillography and Doppler analysis did not correlate. Carbon dioxide tensions showed significant differences only in the recovery time between patients and normal controls.

A 39-year-old white female with multiple arteriovenous malformations of the left foot had had surgical ligation on her left dorsalis pedis artery at age 12 with no clinical improvement. She was placed into a leotard at age 16 and was able to function but would tire very easily and her left foot was twice the size of her right one. In May 1988, she had four large feeder vessels off the posterior tibial artery and two off the anterior tibial artery embolized by use of 1,000 microns PVA particles, occlusive spring coils, and detachable balloons. Her foot shrunk and is now smaller than her normal right foot; she does not tire, and she now wears a knee length stocking to help prevent other channels from opening.

The Circulator Boot is a new end-diastolic pneumatic leg compression device. This report describes its effect on 6 normal young people, 8 ambulatory patients with mild peripheral arterial disease, and 21 consecutive patients (of whom 18 were hospitalized) with severe peripheral arterial disease in 25 legs. The courses of 4 patients are discussed in detail. Significant beneficial effects were documented by subcutaneous PO2 levels, pulse volume measurements, ankle blood pressure measurements, and Doppler ultrasound tracings. Twenty-two of the 25 severe legs benefitted clinically from therapy. Immediate therapeutic effects from the boot are attributed to decreases in venous pressure, interstitial fluid pressure, vasoconstriction, and viscosity, and to increases in cardiac output, pulse pressure, and fibrinolysis in the treated leg. The long-term beneficial effects of boot therapy may be related to improved collateral flow and to the rechanneling of obstructed vessels.

The clinical efficacy of ticlopidine, a platelet aggregation inhibitor, was evaluated in a double-blind placebo-controlled study on 193 patients with ischemic ulcers due to chronic arterial occlusion. In the group treated with ticlopidine, significantly better efficacy was noted over the placebo group in terms of judgment on overall improvement by doctors in charge as well as by the committee assessing with color slide films. The drug was particularly effective for the treatment of patients with occlusion in the arteries on the distal side and for the ischemic ulcer with relatively small size. In the group with ticlopidine, granulation was significantly improved compared to the placebo group. Those patients who had pain due to arterial occlusion on the distal side were significantly improved by this agent. The mean diameters of ulcers were clearly reduced. Therefore, this agent could possibly be claimed as an effective remedy against the main symptoms of chronic arterial occlusion. The frequencies of side effects and abnormalities in laboratory tests were comparable in the group treated with ticlopidine to those of the group with placebo. It was, therefore, concluded that this agent has an outstanding clinical value as a conservative treatment in chronic arterial occlusion.

A plausible explanation for the overwhelming incidence of thromboangiitis obliterans with gangrene in lower limbs (as compared to that in upper limbs) in a series of about 1000 cases is given. Based on that a simple local operative procedure is proposed to replace lumbar sympathectomy in early cases.

Routine diagnosis of suspected occlusive arterial disease of the lower limbs are often based on the pulse absence at the dorsalis pedis artery. However many of these diagnoses are not confirmed after more thorough tests, and this fact arises the problem of the semeiological reliability of the above mentioned artery. Researches carried out by several authors in normal individuals on the dorsalis pedis artery yielded controversial results. Three hundred-sixty subjects free of occlusive arterial disease were then examined by means of clinical and Doppler investigation in order to assess the semeiological reliability of the dorsalis pedis artery in the diagnosis of occlusive arteriopathy of lower limbs, when compared to the posterior tibial one. The conclusion is drawn that a greater semeiological reliability must be attributed to the latter, due to its lesser "absence" incidence.

The radioisotope test using I-131 labelled serum albumin, performed during a period of reactive hyperemia, provides quantitative data which express the rate at which radioactive blood flowing from the leg replaces the non-radioactive blood present in the foot. It has been applied in normal subjects and in patients with arterial occlusions in the lower limbs. High washout rates, i.e. small M/2 index values, were found in the former, whereas low washout rates with higher M/2 indices were observed in the latter. Surprisingly, patients with a very low washout rate could be without subjective symptoms. The usefulness of the test in clinical practice is explained.

Two hundred and eighty-four arteriograms were performed in the hands and feet 178 leprosy patients. Narrowing and tortuosity of the digital vessels, especially in the presence of bone absorption, were constant features. Digital tufts revealed signs of ischemia. However, in the presence of infection, hyperemia was a definite observation. Diminution in the caliber of the digital arteries and thinning or absence of the vascular end loops prove that ischemia plays a vital role in the production of various lesions in leprosy.

Four patients with bilateral arterial insufficiency were treated with i.v. hydroxyethylrutoside for three days (1.5 grs twice a day). All patients experienced relief of symptoms. By continuous registration of subcutaneous nutritional blood flow in the forefoot (by 133Xenon clearance technique) a significant increase in nutritional blood flow of 33% on the average during the second and third hour after medication could be demonstrated. The drug seems to be of use in treating subacute occlusions and thrombosis of arteries in the lower extremity.

Recently, a new procedure for noninvasive measurement of the microcirculation has been developed in the form of a helium-neon-laser Doppler apparatus with which the total erythrocyte flow through a cubic millimeter of skin is quantifiable. The authors used the procedure to examine 17 persons with healthy vessels, 36 patients with a degenerative occlusive disease of the peripheral arteries in Fontaine stages II-IV, and 5 patients with endangiitis obliterans. It is concluded that single measurements do not permit an assessment of microcirculatory conditions but that provocative tests (which are described), especially occlusion tests, make possible valid and reproducible statements and have a high selectivity with respect to the different stages of disease. By repeated measurements followed by calculation of mean values, a further reduction in intraindividual variability among the measurement results can be obtained. Laser-Doppler examinations of the skin constitute a new procedure with which quantitative statements on the blood flow through skin are feasible and from which interesting results can be expected, especially when used as an acute test.

This study posed the question of whether the blood flow properties from the anticubital and ankle vein of healthy subjects varied under different hydrostatic conditions. The blood flow properties from the vena cubitalis and the ankle vein do not vary to any greater degree during lying, whereas during standing the blood viscosity, plasma viscosity, hematocrit, and plasma protein concentration increase significantly. Furthermore, they are significantly higher than in venous blood taken from the arm at the same time. The oxygen partial pressure in venous blood from the arm is significantly higher than in the ankle venous blood after 5 minutes of standing. These results show, among other things, that under the various hydrostatic conditions present in different body regions, the blood flow properties differ considerably. From the pathophysiologic point of view, it is important that during standing the return of blood is made even more difficult because of the increased blood viscosity resulting from fluid loss from the intravascular space to the interstitium.

A radioisotope test using 131I-labelled serum albumin and venous occlusion plethysmography were performed simultaneously on the feet of normal individuals and patients with peripheral arterial disease during a period of reactive hyperemia. The radioisotope test includes a circulation time and a build-up curve reflecting a local clearance process which is characterized by the parameter M/2 -- delay. Between the parameter M/2 -- delay of the radioisotope test and the blood flow measured by the plethysmograph, the power relationship was found to be: M/2 -- delay = 74.01 F-0.74 with r = 0.69. The experimental data show that the plethysmographic blood flow measurement is an accurate method for the assessment of the peripheral circulation in normal individuals but is less suitable in patients with peripheral arterial disease. The radioisotope test appears to be more valuable than the plethysmographic blood flow measurement for the differentiation of normal individuals from patients with peripheral arterial disease and for the evaluation of the grade of ischemia.

Skin blood flux at the dorsum of the foot was measured during local heating--by use of laser Doppler flowmetry--in 6 healthy subjects, 6 claudicants, and 6 patients with rest pain. Significantly different flux increases were noted among the three groups during the first six minutes of heating. Healthy subjects showed an initial rapid increase, followed by an abrupt reduction influx through a probable myogenic autoregulatory microcirculatory control mechanism. In patients the flux increase was slow and continuous, well correlated with the distal perfusion pressure; autoregulatory control was diminished or absent. With less than 100 mmHg perfusion pressure the microvessels are probably constantly dilated through a reduced sympathetic vasoconstriction tone, and further autoregulatory mechanisms are impaired. Measuring of functional behavior of cutaneous microcirculation under low arterial inflow pressure could represent a method for sensitive diagnosis of arterial insufficiency.

Skin blood flow in the microcirculation of the distal foot was evaluated in patients with vascular disease and diabetes and compared with that in normal volunteers by use of laser-Doppler flowmetry. Resting flow (RF) and the flow on standing (SF) were measured in a room at constant temperature (20-22 degrees C). RF was significantly different in the five groups, being increased in patients with diabetes (in comparison with normal volunteers) and decreased in patients with intermittent claudication, rest pain, and ischemic limbs. The venoarteriolar reflex (in response to standing) was also decreased or abolished in diabetic and in all vascular patients. After treatment of all vascular patients with nifedipine (10 mg tid) for one week, there was a significant increase in RF in all patients. The venoarteriolar reflex was improved but still remained below the normal limit. In conclusion laser-Doppler flowmetry is useful both for differentiating classes of different vascular patients and for evaluating the microcirculatory changes induced by nifedepine.

The calcium-blocking agent nifedipine, which possesses vasodilating potency, was tested in 8 patients with peripheral arterial insufficiency. 10 mg sublingually significantly decreased systolic arm and ankle blood pressure. Neither blood flow nor local peripheral resistance in the calf and the forefoot at rest and the calf during postischemic reactive hyperemia changed significantly. During postischemic hyperemia in the forefoot, the drug significantly reduced peak blood flow and increased local peripheral resistance. The drug-induced reduction in forefoot peak blood flow was correlated to the fall in systolic arm and ankle blood pressure. It is suggested that nifedipine may shorten the claudication distance in patients with peripheral arterial insufficiency.

A diabetic patient is described who developed one-sided neuropathic ulceration. Noninvasive microvascular measurements during distant cooling and inspiratory gasp revealed signs of sympathetic denervation. The initially elevated total skin blood flow measured by laser Doppler equipment and decreased capillary perfusion as determined by transcutaneous oxygen tension measurements were both partially restored after treatment with the alpha 1-sympathicomimetic ephedrine. The improvement occurred once more after rechallenge. In conclusion this study further supports the hypothesis of a capillary steal phenomenon caused by extreme vasodilation within sympathetically denervated arteriovenous shunt vessels.

Hemodynamic variables were used to evaluate the effectiveness of lumbar chemical sympathectomy in 20 patients with ischemic foot lesions. Early clinical improvement was obtained in 68% of the cases. The two-year cumulative limb salvage rate was 52%. Results indicate that lumbar chemical sympathectomy offers the same benefits as surgical sympathectomy and represents a useful alternative in patients with advanced ischemic disease of the lower limb, decreasing the rate and the level of amputations.

A total of 102 cases of ischemic ulcers, some with superficial gangrene and infection, were treated in a conservative manner, including debridement when indicated. Results with the outline of care described were very encouraging, with a limb salvage rate of over 90%. It should be stressed that diligent observation and care of the patient being treated is essential.

Microangiopathy is one of the most frequent diseases in diabetic patients. A diabetic man with a kidney transplant and with severe and progressive vasculopathy with early necrosis of the fingers and toes was submitted to three prostacyclin (PGI2) intravenous infusions (5 ng/kg/min for forty-eight hours) during a period of two months. Three months after the last infusion, radiographs of the hands and feet showed a marked reduction in the extent of the vascular calcifications and healing of the ischemic-necrotic areas. The authors discuss the immediate and later effects of PGI2 infusion in a case of diabetic vascular disease.