Hemodynamic assessment of aortoiliac occlusive disease is necessary for successful arterial reconstruction of the aorta and legs. Various methods have been proposed and "pull-through" intra-arterial pressures are the "gold standard." Deep Doppler duplex imaging was supplemented with real-time spectral analysis and velocity measurements in 29 cases. Twenty-three of these patients needed arteriography. One hundred sixty-six (166) arterial segments extending from the proximal aorta to the common femoral arteries were independently graded on duplex scans and arteriograms. For severe occlusive disease, duplex scanning is highly accurate (sensitivity 82%, specificity 93%). Velocity measurements were useful in determining the hemodynamic significance of stenoses. Peak systolic velocities in stenoses were measured with a duplex scanner. The pressure gradient calculated with the modified Bernoulli equation (delta P = 4Vmax2) correlated well with the gradients measured during arteriography (r = 0.9, n = 11). These noninvasive velocity measurements and Bernoulli calculations alert arteriographers to obtain special views of suspected areas and suggest the need for "pull-through" pressures and possible balloon angioplasty. In addition, these noninvasive measurements are useful to follow up patients who have mild to moderate aortoiliac disease and after angioplasty.
Controversy regarding efficacy and durability of distal bypass grafting of the diabetic patient exists. A 22-year-long series of 259 vascular procedures with 100% follow-up (57% in diabetic individuals) is examined to compare these results with those of non-diabetic patients. Extensive review of predisposing factors, operative indications, preoperative medical evaluation, as well as techniques and peculiarities of angiography is rendered. Peripheral arterial case mix between the two groups is examined. The high utilization rate of solely venous conduits (94%) in diabetics compared with 76% in nondiabetics, along with anastomosis site selection, provides the most reasonable explanation for the successful outcome in both groups. Modifications in revascularization techniques contributing to successful outcome are presented. In the diabetic patients, both the cumulative graft patency rate (63%) and the limb salvage rate (77%) at 6 years were superior to those of the non-diabetics (52% and 65%, respectively). Diabetes mellitus does not predispose the person requiring revascularization for limb salvage to a lesser likelihood of success.
The management of asymptomatic carotid stenosis remains controversial. From December 1983 to December 1987, 188 symptom-free patients were found to have severe (>75%) stenosis by duplex imaging (performed as screening examination). Patients with nonhemispheric symptoms or contralateral symptomatic lesions (within 7 years) were excluded from the study. Follow-up data were available for 141 patients (range 3 to 36 months; mean 21 months). Sixty-two patients received nonoperative therapy. The remaining 79 patients underwent 100 carotid endarterectomies (CAE) (21 staged bilateral repairs and 58 unilateral repairs). There were no statistically significant differences in sex, age, or risk factors (i.e., hypertension, diabetes, or smoking) or in the incidence of bilateral disease. Significant differences were found in the incidence ofischemic attacks (0 vs 21%; p < 0.001) and stroke (2.5% vs 18%; p < 0.01) in the operative vs nonoperative group. None of the 11 strokes in the nonoperative group were preceded by neurologic events. The operative group had an overall stroke rate of 2.5% (2/79), a perioperative mortality rate of 1.3% (1/79), and a restenosis (>50%) rate of 3.8% (3/79). Thus favorable results can be achieved with prophylactic CAE. These data support the use of prophylactic CAE in any patient with greater than 75% stenosis identified by duplex image, regardless of sex, age, risk factors, or bilateral disease. (J VAsc SURG 1989;9:361-6.) Controversy exists over prophylactic carotid endarterectomy (CAE) in symptom-free patients. The Framingham study 1 and others 2 suggest a stroke risk of 0.1% to 0.4% per year in symptom-free patients. The marker of disease in these studies was the presence of a bruit and not necessarily documented stenosis. When a stenosis is found, however, the risk of stroke increases to 0.7% to 6%Y Recent reports by Hertzer et al. 6 and Moneta et al. 7 have demonstrated a beneficial result ofendarterectomy in reducing transient ischemic attacks (TEAs) and stroke in symptomfree patients with >75% diameter stenosis. However, Hertzer et al. could demonstratc a reduction of _~roke risk only in symptom-free male patients. Still others report no benefit of prophylactic endarterectomy in any patients. 3-5,s-~° Because the presence of a bruit does not correlate well with significant internal carotid stenosis, s'9 other screening maneuvers have been developed. Noninvasive tests, in particular duplex scanning, has been well documented to be a reliable screening tool for the detection of carotid stenosis, n The results of du-From the
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