lose monitoring of the peripheral circulation is critical for the management of intensive care unit (ICU) patients, including particularly those who have just had open-heart surgery. Although peripheral temperature monitoring of the extremities is a simple method to diagnose peripheral circulatory disturbance, it does not provide a quantitative assessment. The systemic vascular resistance (SVR) index (SVRI) is an objective and standard measure of the peripheral circulation, but calculation of SVRI requires the determination of cardiac output (CO; in L/min) through invasive examination or the use of sophisticated equipment. CO is estimated non-invasively from oxygen uptake during exercise, 1 but the calculation of SVR needs central venous pressure (CVP: in mmHg) or mean right atrial pressure measurements. 2 Therefore, the development of a quantitative method to evaluate peripheral circulatory disturbance non-invasively is important.Resistive index (RI) is a parameter that not only indicates the absolute value of blood flow velocity but also reflects changes in Doppler waveforms. In the urology field, RI is used in the evaluation of the severity of impaired blood circulation following renal transplantation and progressive nephropathy. However, RI has mainly been used for evaluating blood flow to a target organ, but not for hemodynamics. In patients with extreme hemodynamics, including those who have had open-heart surgery and following an emergency, it is very important to know the impairment of the peripheral circulation; therefore, if RI could be used simply to quantify systemic blood vessel resistance, it could be an important parameter for circulation control, based on a different perspective from that of cardiac output and oxygen saturation of mixed-venous blood. Here, we measured RI in the upper extremity arteries, examined the most effective point of measurement, and determined whether this technique allows for the quantitative evaluation of peripheral circulatory disturbance. Methods Measurements of RIAt each measurement point, a 7.5 MHz probe was positioned on the measurement surface and a target artery (simulated peripheral artery in vitro) was imaged in B mode. A site with the minimum ultrasonic incidence angle was selected in the artery on display and pulsed Doppler ultrasonography was conducted. The systolic maximum velocity (Vmax) and diastolic minimum velocity (Vmin) of the pulsed Doppler waveforms were determined and Background To explore an alternative to the systemic vascular resistance index (SVRI) for monitoring peripheral circulation in patients in the intensive care unit (ICU), the resistive index (RI) in the upper extremity arteries was measured by using surface Doppler ultrasound. Methods and ResultsThe correlation between RI and vascular resistance was assessed in vitro using a vessel phantom in a Donovan-type mock circulation system. In addition, 15 ICU patients who had undergone open-heart surgery were studied. Mean arterial pressure, central venous pressure and cardiac output were measu...

When a patient with Ehlers-Danlos syndrome (EDS) presents with a vascular emergency, performing life-saving surgery can be difficult because of the profound fragility of the arterial tissue. We report the case of a 27-year-old woman with EDS in whom a spontaneous arterial rupture was successfully treated with transcatheter embolization. The patient was brought to our hospital in shock, with left lower abdominal pain. She had been diagnosed with EDS type IV following a colonic rupture 8 years earlier. An emergency angiogram revealed rupture of the left external iliac artery. The active bleeding was managed by transarterial embolization of the ruptured artery using stainless steel coils, which took 30 min to achieve. The patient has not suffered any further vascular complications during the year since this procedure. Transcatheter coil embolization may be a reliable option for treating sudden arterial rupture in patients with this syndrome.

Extra-anatomic bypass is preferred for revascularization after removal of infected vascular grafts. The obturator canal technique has been used to bypass an infected field in the groin, although this method has not always been definitive because of several drawbacks. We present a unique method of extra-anatomic revascularization for use in such a situation. An autogenous graft is placed just below the sartorius muscle in the thigh and penetrates the iliacus muscle near the lateral end of the inguinal ligament. Limb loss and recurrent infection are prevented postoperatively. This retro-sartorius bypass technique may be a useful alternative to obturator bypass grafting in selected patients.

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Precise measurement of Doppler estimated blood flow volume using the standard technique of flow-mediated vasodilation is not possible because the anatomic course of the brachial or radial artery goes against the principle of Doppler measurements that the insonation angle should be less than 30 degrees . The radial artery in the anatomic snuff-box area is useful for the measurement of Doppler signals as the insonation angle is less than 30 degrees and because the size of the artery allows observation of laminar flow. We introduce the snuff-box technique as a novel endothelial function test that enables measurement of both blood flow and diameter of the radial artery. Changes in diameter and blood flow volume during reactive hyperemia were examined in 15 healthy volunteers. Changes in blood flow determined using the snuff-box technique were compared with changes in forearm blood flow determined by plethysmography. The diameter of the radial artery increased from 2.3 +/- 0.2 mm at baseline to 2.8 +/- 0.4 mm at 60 s after deflation (P = 0.0017), and blood flow increased from 52.3 +/- 21.4 ml/min at baseline to 108.6 +/- 33.1 ml/min at 15 s after deflation (P = 0.0014). Percentile blood flow determined by the snuff-box technique correlated significantly with that determined by plethysmography (r = 0.824, P = 0.0002). Both blood flow volume and artery diameter can be measured with high reliability using the snuff-box technique, as has been shown in subjects with reactive hyperemia.