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Early postoperative changes in the hemodynamic parameters of infrainguinal bypass grafts in diabetics have not been well defined. We undertook this study to better define such changes in duplex-derived velocities and waveforms, and correlate any observed changes with intermediate-term outcomes. A prospective study of 68 primary vein bypasses for limb salvage was carried out, with scans obtained intraoperatively, daily until discharge, and at 8- to 12-weeks intervals. During follow-up (12 +/- 6 months), 20 grafts developed stenoses, 17 occluded, and 8 limbs were amputated. Most grafts show a variant of a biphasic waveform intraoperatively at the mid-graft (MG) and distal graft (DG) levels (54% and 57%); 65% of waveforms remain unchanged during the first week, and 54% remain unchanged at 3 months. No duplex-derived factors were predictive of the development of stenoses. A number of parameters were predictive of ultimate graft thrombosis. Intraoperative MG velocity was higher in grafts that eventually remained patent (83 +/- 36 vs. 60 +/- 29 cm/sec; p <0.025). Grafts that remained patent also had a much lower decline in DG and distal native (DN) velocities from immediately postoperative to 8-12 weeks later, than grafts that eventually thrombosed (-3 +/- 35 vs. -44 +/- 43 cm/sec for DG, p <0.001; and -17 +/- 66 vs. -76 +/- 53 cm/sec for DN, p <0.04 respectively). In terms of limb salvage, when the MG or DG waveform worsened (from postoperation to 12 weeks later), amputation was more likely than when it remained unchanged or improved (MG 67% vs. 9% limb loss, p <0.04; DG 43% vs. 8% limb loss, p <0.04). We conclude that intensive graft duplex surveillance does not identify grafts likely to develop stenoses. However, a number of features allow the prediction of ultimate graft failure or limb loss.

Patients with peripheral vascular disease are susceptible to neuropathy from chronic hypoxia. We wished to determine whether revascularization of chronically ischemic limbs results in any clinical changes in peripheral sensory thresholds. We prospectively measured quantitative vibration perception thresholds (VPT) using a Horwell neurothesiometer (in volts) in patients undergoing infrainguinal bypass, preoperatively and up to 6 month postoperatively. The bypassed limbs' preoperative VPT values were higher (lesser sensory perception) than the contralateral control limbs' preoperative values (mean score differences: 6 +/- 2 and 4 +/- 10 at toe and foot levels respectively; p ? 0.004). Preoperative VPT values were not different from the 6-month postoperative values for the revascularized legs at toe and foot levels for all 55 patients (mean score change of ?0.84 and ?1.32, p > 0.5). The contralateral limbs' VPT values did not change significantly over the 6-month period (mean change scores of 2.9, p > 0.15, and 2, p > 0.30, for toe and foot, respectively). A comparison of preoperative values between limbs that were eventually amputated and saved revealed no statistically significant differences. This study suggests that revascularization does not result in a clinically detectable improvement in sensory neuropathy. It may, however, prevent further degradation. The degree of preoperative neuropathy does not affect outcome in terms of limb salvage.

A retrospective review of 101 diabetics without aortoiliac disease was carried out to analyze the ability of various noninvasive tests to predict the level of significant (>50% stenosis) infrainguinal arterial disease. Patients were studied with anklebrachial indices (ABI), toebrachial indices (TBI), segmental pulse volume recordings (PVR), segmental pressures (SEGP), segmental Doppler waveforms (DWF), and arteriography. Results were classified as normal, disease at the femoropopliteal level, infrapopliteal level, or both levels (multilevel), or noninterpretable. Our findings for the entire study showed that, as a single test, DWF appears to have the best angiographic correlation, although the summed diagnosis of combined DWF and PVR data is superior in distinguishing multilevel disease from isolated tibial disease. SEGP are of very limited use in diabetics, even in multimodality testing, and we no longer include that test in our routine evaluation of diabetics.

We report a rare case of primary aortoduodenal fistula (ADF) secondary to a Coxiella burnetii (Q fever) infection in a patient with an abdominal aortic aneurysm. A review of the available literature on the vascular complications of Q fever is presented. Q fever should be suspected in vascular patients with close animal contact when a standard infectious work-up is unrevealing. Diagnostic steps and management strategies for primary ADF are also briefly reviewed.