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Patients with abdominal aortic aneurysms may present with a variety of special clinical problems. An unusual case of coexistent aortic aneurysm, atherosclerotic occlusive disease, and chronic lymphocytic leukemia in a 77-year-old man is presented.

Proper selection of suprainguinal vs. infrainguinal arterial revascularization in patients with multilevel disease requires hemodynamic assessment. In such patients hemodynamic evaluation of the aortoiliac system cannot be made accurately with either arteriography or current noninvasive techniques. One hundred six lower extremities underwent preoperative triplane arteriography, measurement of Doppler-derived segmental blood pressures, measurement of common femoral intra-arterial pressure, and intra-arterial injection (30 mg) of the vasodilator papaverine hydrochloride prior to arterial bypass. Common femoral intra-arterial pressure was monitored continuously before and after papaverine injection. The resting femoral/brachial pressure index (FBI) and the maximum change in this index (% delta FBI) following papaverine injection were calculated. To be considered improved postoperatively, claudicants required an increase in treadmill walking time of greater than or equal to 50%, whereas patients operated on for limb salvage required an increase in the thigh/brachial pressure index (TBI) of greater than or equal to 0.15 for suprainguinal revascularizations and an increase of TBI to greater than or equal to 0.9 for infrainguinal revascularizations. In the first 41 extremities (phase I), receiver operator characteristic analysis revealed a % delta FBI greater than or equal to 15% to be optimal in the detection of hemodynamically significant aortoiliac disease. In phase II (65 limbs) this discriminant value for % delta FBI was assessed prospectively. In phase I, in which the choice of supra- vs. infrainguinal bypass was determined arteriographically, only 80% of the extremities were improved; in phase II, in which supra- vs. infrainguinal bypass was determined by the papaverine test, 98% of extremities were improved (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Amputation done on an emergency basis of severely ischemic or infected limbs in critically ill patients frequently results in increased morbidity and mortality. To evaluate the effect of delaying an inevitable operative amputation by a simplified method of freezing the involved extremity, the records of 56 patients who underwent preoperative cryoamputation during a 12-year period were reviewed. Data concerning risk factors, associated medical conditions, local or systemic signs of sepsis, level of amputation, morbidity, and mortality were analyzed. Following cryoamputation of 57 limbs, 16 above-knee amputations (AKA) and 41 below-knee amputations (BKA) were performed. The overall mortality rate associated with cryoamputation was 14% (8 of 57); four postoperative deaths occurred in both the AKA and BKA groups. The mortality rate for 1021 primary operative major amputations during the same period was 7% (p less than 0.04). The only factor identified that significantly affected survival following cryoamputation was diabetes mellitus, which was present in 68% of surviving patients and in 12% of those who died (p less than 0.001). This experience suggests that cryoamputation is a valuable, simple technique that allows for deliberate stabilization and preparation of seriously ill, septic patients prior to surgical procedures, which, when performed on an emergency basis have been associated with mortality rates exceeding 40%.

Although various techniques to determine amputation level have become available, obvious clinical factors may yet identify patients in whom a major amputation is unlikely to heal. We have analyzed the association of multiple clinical factors with the morbidity of 1028 consecutive amputations performed in 786 patients during a 13-year period. The overall operative mortality rate was 7% (57 of 786 patients). Cardiac complications were the leading cause of death (43%). In the 729 patients surviving operation, 345 above-knee amputations (AKAs) and 626 below-knee amputations (BKAs) were performed. After operation, 15.4% of these amputations failed to heal and required proximal revision. The AKA failure rate was 9% and the BKA failure rate was 19%. Significantly higher failure rates were noted in whites, nondiabetics, and those patients with heart disease. It is concluded that major amputation continues to be associated with significant morbidity and mortality rates despite changes in perioperative care and surgical technique. Common clinical characteristics indicate high-risk patients in whom a BKA is unlikely to heal and who may benefit from prospective attempts to determine amputation level.

Prolonged arterial spasm as a complication of ergot-containing medications has been reported since antiquity. This article describes our experience with a patient who had severe bilateral arterial spasm in the upper extremities 6 days after the initiation of a regimen of dihydroergotamine and heparin for prophylaxis against deep venous thrombosis. The spasm was refractory to oral calcium channel blocking agents and direct intraarterial infusion of tolazoline (Priscoline). However, intraarterial nitroglycerin produced a prompt and dramatic improvement in symptoms and in physical and arteriographic findings. This experience suggests that intraarterial nitroglycerin may be an appropriate first choice for ergot-induced arterial spasm.

Previous attempts to quantify blood flow by means of ultrasound have been hampered by inaccurate diameter measurements and failure to account for the parabolic nature of the cross-sectional velocity profile. Angiodynography (ADG) provides a B-mode image of vessel walls, and the outer flow envelope is constantly monitored to provide phasic diameter measurements throughout the cardiac cycle. Frequency shifts are color-coded to provide a real-time visual display of varying velocity patterns across the vessel lumen throughout the cardiac cycle as well as calculation of average flow velocity and mean blood flow. Simultaneous flow values obtained with ADG were compared with electromagnetic flow probe (EMF) measurements in 12 open-chest dogs. Flow was varied with volume administration and exsanguination, and 201 data points were obtained. The average flow determined by EMF was 2.0 +/- 0.9 L/min compared with 2.04 +/- 0.71 L/min for ADG. The correlation coefficient was 0.88, the y-intercept was close to zero, and the slope approached unity, confirming the ability of ADG to accurately determine volume blood flow rather than merely to establish a flow trend. It is concluded that ADG offers an accurate way of quantifying volume blood flow.