The natural history and prognosis of Takayasu's arteritis still remain poorly defined.

A controlled, prospective study comparing streptokinase and heparin treatment has been completed in 51 patients presenting with acute proximal venous thrombosis of less than 8 days' clinical duration. Patients were studied by means of pre-treatment, post-treatment, 3- and 12-monthly phlebography and pulmonary perfusion scanning and were followed up at 3-monthly intervals. Of the 26 patients randomized to receive streptokinase, therapy was stopped in 3 because of complications. Phlebography 5 days after starting treatment showed 80--100 per cent lysis in 17 of the 23 patients who completed the course of streptokinase. Two patients later developed partial rethrombosis. One patient developed an asymptomatic pulmonary embolus during treatment. During follow-up (mean 19 months) only 1 of the 17 patients with 80--100 per cent lysis developed postphlebitic symptoms, 3 patients died of unrelated causes and 1 patient was lost to follow-up. In patients randomized to heparin therapy no significant lysis was achieved in any of the 25 patients and only 2 of these patients were found to have asymptomatic legs on follow-up. Two patients in this group died and autopsy confirmed massive pulmonary embolus during treatment. These data suggest that streptokinase is superior to heparin in the treatment of acute proximal venous thrombosis of less than 1 week's clinical duration especially if the thrombus is largely non-occlusive. It must be stressed that in order to avoid the bleeding complications of thrombolytic therapy, streptokinase must not be used within 10 days of major surgery, or even longer after vascular, neurosurgical or eye operations.

Angiography and intervention is of great benefit in the diagnosis and management of traumatic vertebral artery injuries. Angiography often avoids unnecessary exploration and permits endovascular treatment.

Transmetatarsal amputation (TMA) for peripheral vascular disease has the reputation of being an operation with a poor outcome. This retrospective study reviewed a 3-year consecutive series of TMA in diabetic and nondiabetic patients. All amputations performed for peripheral vascular disease at Groote Schuur Hospital from January 1999 to December 2002 were reviewed. Data were obtained from hospital records and operating theatre books. The following groups were defined for the purpose of this retrospective study: group 1, TMAs performed in diabetic patients; group 2, TMAs done in nondiabetic patients. Altogether, 43 TMAs were performed: 27 in group 1 and 16 in group 2. Perioperative mortality rates were 7% and 4%, respectively. Overall, the healing rate was 67%: 62% (17/27) in group 1 and 75% (12/16) in group 2. The median times to healing were 8 months in group 1 and 7 months in group 2. Toe pressure and the presence of advanced tibioperoneal disease influenced the outcome of TMA in diabetic patients. Transmetatarsal amputation with a healed stump provided our patients with good mobility. Prediction of healing after operation is unreliable. There was no statistical difference in outcome in diabetic (group 1) versus nondiabetic (group 2) patients.

One hundred and thirteen consecutive patients admitted with a perforated duodenal ulcer over a 5-year period (1978-82) and treated by simple closure have been followed prospectively over a median period of 43 months. Patients were divided into two categories according to their previous history of dyspepsia; group 1 (66 patients) with a chronic history of more than 3 months and group 2 (47 patients) where there was no history of dyspepsia or a history of less than 3 months duration. The follow-up periods were similar (group 1, 44 months; group 2, 43 months). The overall recurrence rate was 42 per cent and to date only 14 per cent of the total group of 113 patients have required a definitive operation. The incidence of ulcer recurrence was higher in group 1 than in group 2 in terms of total recurrence (group 1, 50 per cent; group 2, 32 per cent) and patients requiring further surgery (group 1, n = 14, 21 per cent; group 2, n = 7, 15 per cent). Five of these 21 patients required an emergency procedure for haemorrhage or reperforation (group 1, n = 2; group 2, n = 3). There were no significant differences between the 5-year predictive recurrence rate or the requirement for definitive surgery between the groups. Five of the 27 patients currently on medical treatment have required maintenance treatment while the remaining patients receive active treatment for a mean of 20 per cent of the time since they developed recurrent ulceration. These results support continuation of our 'wait and see' policy following simple closure of perforated duodenal ulcer, even in patients with a history of chronic dyspepsia.

This review examines the role of graduated elastic compression stockings in the prevention of postoperative deep vein thrombosis. Used alone compression stockings reduce the incidence of postoperative deep vein thrombosis by approximately 60 per cent and when used in combination with other preventive methods, such as low dose heparin or intermittent calf compression, they further reduce the incidence by up to 85 per cent.

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SUMMARYTwo cases of phlegmasia caerulea dolens with peripheral uenous gangrene treated with streptokinase are presented. Both patients had excellent results, beyond expectation. The literature is veviewed and the symptomatology, ae tiology, pathogenesis and current thoughts on treatment are discussed.PHLEGMAsrA caerulea dolens is a rare, but potentially lethal, form of venous thrombotic disease. It is reversible, but may result in gangrene, pulmonary embolism or even death. Other terms describing the same entity include blue phlebitis ('la phlebite bleu de Gregoire') or acute massive venous thrombosis. The most severe form of this disease is venous gangrene. Haimovici (1 966) groups phlegmasia caerulea dolens and venous gangrene under the heading of 'ischaemic thrombophlebitis', as the dominant manifestation is tissue ischaemia. I n caerulea dolens the ischaemic changes are reversible as opposed to those of venous gangrene. The basic pathological condition in caerulea dolens is near total venous thrombotic occlusion, whereas in venous gangrene, there is total occlusion. In spite of being recognized for some 400 years, caerulea dolens still has a mortality of approximately 25 per cent and an amputation incidence of 50 per cent. Treatment has evolved from conservative medical management to venous thrombectomy, which has produced some improvement in immediate results. Since 1970 several reports (Paquet et al., 1970;Tsapogas et al., 1973;Roberts, 1976) have shown excellent results after treatment of caerulea dolens with streptokinase. In view of this and also because of the known poor long term results after thrombectomy (Lansing and Davis, 1968; Johansson et al., 1973), we used streptokinase in the treatment of 2 recent cases of caerulea dolens with venous gangrene, with extremely satisfactory results. Case reportsCase 1 : A 43-year-old female developed an iliofemoral thrombosis in her left leg. She was treated with heparin for 7 days and then given warfarin. On the third day of warfarin therapy, when the prothrombin index was 36 per cent, she developed severe pain in her left leg, which was uncontrolled even with heavy doses of morphine. Eight hours later the forefoot was cold and blue. A tentative diagnosis of an acute arterial occlusion was made and she was transferred to Groote Schuur Hospital. On arrival her temperature was 38.5 "C, respiration 38/min, pulse 148/min and her blood pressure was 140/80 mmHg. Local examination revealed the left leg to be grossly swollen to above the inguinal ligament and the lower leg mottled and blue. The distal left foot was blue-black and anaesthetic (Fig. 1): No movement was possible at either the ankle or the knee joint due to the oedema and extreme pain. No pulses could be detected in this limb, but Doppler examination revealed that all were audible, though diminished.A diagnosis of massive venous occlusion with peripheral venous gangrene was made. The leg was elevated, intravenous penicillin given and streptokinase (Kabikinase, AB Kabi, Stockholm) therapy commenced using the...