Color duplex scanning in the evaluation of endovascular interventions into autovenous shunts

The paper describes a role of color duplex scanning (CDS) in the assessment of results of endovascular interventions into autovenous shunts, including in situ ones. From 2000 to 2005, the unit of vascular surgery of Clinical Hospital No. 83 performed 148 femoropopliteal and femototibial repairs, including the in situ technique, in 138 patients with atherosclerosis obliterans and stenotic and occlusive changes in the femoropopliteal segment and shin arteries. CDS monitoring revealed 42 shunts with hemodynamically significant changes, which was an indication for preventive endovascular operations --balloon angioplasty (BAG) and in one case for autovenous shunt stenting. According to CDS data, an adequate endovascular intervention with restoration of the geometry of shunts or their anastomoses was performed in 40 (95.2%) cases, by recording the great bloodstream; there were hemodynamically significant complications (residual stenoses) in 2 (4.8%) cases and hemodynamically insignificant ones in 5 (12%). In the late period, hemodynamically significant complications (thromboses and restenoses of an angioplasty site) and insignificant restenoses were detected in 14 (33%) and 5 (12%) cases, respectively. After endovascular intervention, supplemented shunt patency was 40.89 +/- 18.5% with the average follow-up length of 23.3 +/- 2.3 months. Based on the complications detected at a hospital stage and in the late follow-up period after preventive primary endovascular intervention, 10 endovascular reinterventions were performed, which increased patency time in the group of endovascular reinterventions into the shunts by 19.6 +/- 3.8 months. Thus, the developed echosemiotics of shunts, including an in-situ autovenous shunt permits evaluation of the state of a shunt and the hemodynamic significance of the found changes in due time and early at surgery. CDS monitoring makes it possible to specify indications for preventive operations, to choose a repeated reparative procedure in a patient with thromboses of femoropopliteal and femorotibial segments.     

Role of duplex scanning in the diagnosis of erectile dysfunction

A total of 110 patients aged 34-74 years who complained of erectile dysfunction (ED) were examined. A control group of 9 patients without complaints of ED was formed to determine the normal condition. Baseline ultrasonography was followed by scanning after intracavernous administration of a vasoactive drug to whose use 59 individuals contended to. In the control group, the variation of PSV values was in the range of 23-59 cm/sec. Among the patients with complaints of ED, the baseline study has indicated normal PSV values in both cavernous arteries in 21 cases of the 110 patients; in the other patients, the baseline cavernous arterial blood flow, such as that in the great arteries, was less than 30 cm/sec. Summing up the data of observations of 59 patients undergone erectile stimulation has ascertained that that 20, 34, and 4 patients were diagnosed as having the isolated arterial form of ED, the arteriovenous form, and venous form, respectively; there was no evidence for the form of vascular genesis in 1 patient. Ultrasonography, including color duplex scanning with Doppler energy flow mapping, and B-mode before and after erectile stimulation with intracavernous administration of an E1-prostaglandin drug, makes it possible to assess the contribution of the vascular component to the pathogenesis of erectile dysfunction.     

Evidence for greater burden of peripheral arterial disease in lower extremity arteries of spinal cord-injured individuals

Spinal cord injury leads to increased risk for cardiovascular disease and results in greater risk of death. Subclinical markers of atherosclerosis have been reported in carotid arteries of spinal cord-injured individuals (SCI), but the development of lower extremity peripheral arterial disease (PAD) has not been investigated in this population. The purpose of this study was to determine the effect of spinal cord injury on ankle-brachial index (ABI) and intima-media thickness (IMT) of upper-body and lower-extremity arteries. We hypothesized that the aforementioned measures of lower-extremity PAD would be worsened in SCI compared with controls and that regular participation in endurance exercise would improve these in both groups. To test these hypotheses, ABI and IMT were determined in 105 SCI and compared with 156 able-bodied controls with groups further subdivided into physically active and sedentary. ABIs were significantly lower in SCI versus controls (0.96 ± 0.12 vs. 1.06 ± 0.07, P < 0.001), indicating a greater burden of lower-extremity PAD. Upper-body IMTs were similar for brachial and carotid arteries in controls versus SCI. Lower extremity IMTs revealed similar thicknesses for both superficial femoral and popliteal arteries, but when normalized for artery diameter, individuals with SCI had greater IMT than controls in the superficial femoral (0.094 ± 0.03 vs. 0.073 ± 0.02 mm/mm lumen diameter, P < 0.01) and popliteal (0.117 ± 0.04 vs. 0.091 ± 0.02 mm/mm lumen diameter, P < 0.01) arteries. The ABI and normalized IMT of SCI compared with controls indicate that subclinical measures of lower-extremity PAD are worsened in individuals with SCI. These findings should prompt physicians to consider using the ABI as a screening method to detect lower-extremity PAD in SCI.     

Bone reconstruction of the lower extremity: complications and outcomes

A study was performed to analyze the results and final outcomes of bone reconstruction of the lower extremity. Twenty-six patients presented with type IIIB open fractures, nine with type IIIC open fractures, and 15 with chronic osteomyelitis. Seven patients underwent primary amputation, and reconstruction was attempted for 43 patients. The mean bone defect size was 7.7 cm (range, 3 to 20 cm). Bone reconstruction was achieved with conventional bone grafts in 16 cases, in association with either local (13 cases) or free (three cases) flaps. Vascularized bone transfer was performed in 24 cases, with either osteocutaneous groin flaps (10 cases), soleus-fibula flaps (12 cases), or osteocutaneous lateral arm flaps (two cases). For three patients, bone reconstruction was performed with a technique that combines the induction of a membrane around a cement spacer with the use of an autologous cancellous bone graft. Infections were observed to be responsible for prolonged hospital stays and treatment failures. The cumulative rates of sepsis were 4.6 percent at 1 week after injury and 62.8 percent at 2 months. Vascular complications were also related to infections and were responsible for four secondary amputations. One patient asked for secondary amputation because of a painful nonfunctional lower limb. Bone healing occurred in 37 of 43 cases, and the average time to union was 9.5 months, with an average of 8.7 procedures. The mean lengths of stay were 49 days for conventional bone grafts and 62 days for vascularized bone grafts. All of the 50 patients were able to walk, with an average time of 14 months. All of the patients with amputations underwent prosthetic rehabilitation. Patients mostly complained about the reconstructed limb (62.8 percent). Joint stiffness was present in 40 percent of the cases. Other long-term complications were pain (nine cases), lack of sensation (five cases), infection (five cases), and pseudarthrosis (one case). However, all of the patients with successful reconstructions preferred their salvaged leg to an amputation. Of 41 patients who were working before the injury, 26 returned to work.     

Management of compound injuries of the lower extremity.

The reconstructive surgeon experienced in the use of rotated or free muscle and myocutaneous flaps, skilled in microvascular surgery, and interested in lower extremity trauma, may favorably alter the course of management of these historically difficult problems. It can be of great advantage to the patient if this surgeon is involved in the primary evaluation, so that all initial therapy can be performed with the future reconstructive goals in mind.     

Anatomy of arteries of the upper extremity in various chromosomal and gene mutations

Changeability of major + arteries and their main branches has been studied in 159 preparations of the upper extremities of fetuses, newborns and children of suckling age with trisomies of 13, 18, and 21 chromosomes, anencephaly in newborns, died at asphyxia or birth injury without any visible developmental defects. Manifestation of anatomical changeability in the human being is under an essential influence of peculiarities of genotypes. In morphogenesis of the upper extremity arteries genes of 13, 18 and 21 chromosomes participate. Trisomies of 13, 18 chromosomes cause more manifested and specific changes in morphogenesis of some structures, and trisomy 21 and mutant genes, producing anencephaly , only increase variability of their structure.     

Optimal cut-off criteria for duplex ultrasound for the diagnosis of restenosis in stented carotid arteries: Review and protocol for a diagnostic study

Background  

Carotid angioplasty with stenting is a relatively new, increasingly used, less-invasive treatment for the treatment of symptomatic carotid artery stenosis. It is being evaluated in ongoing and nearly finished randomized trials. An important factor in the evaluation of stents is the occurrence of in-stent restenosis. An un-stented carotid artery is likely to have a more elastic vessel wall than a stented one, even if stenosis is present. Therefore, duplex ultrasound cut-off criteria for the degrees of an in-stent stenosis, based on blood velocity parameters, are probably different from the established cut-offs used for un-stented arteries. Routine criteria can not be applied to stented arteries but new criteria need to be established for this particular purpose.     

The three-dimensional determination of internal loads in the lower extremity

A three-dimensional model of the lower limb containing 47 muscles was developed to study the differences between a two- and three-dimensional approach for determining internal loads, the role of the dynamic joint representation, and the behavior of different load-bearing criteria in walking and running. The problem of redundancy of the musculo-skeletal system was resolved by applying inverse dynamics and static optimization methods. Different hypothetical load-bearing capabilities of hinge, spherical and intermediate joint types for the knee and the ankle joints were tested. It was found that even almost planar movements such as walking and running are associated with significant three-dimensional intersegment moments, especially in the frontal plane. Thus, a two-dimensional approach may underestimate internal loads up to 60%. It is shown that pure hinge joints are inappropriate for modeling the dynamical joint function of the knee and ankle joints. A more flexible joint representation in combination with a squared muscle stress minimization criterion predicted a lot of synergistic as well as antagonistic muscle activation which was also found in the EMG patterns. The results indicate the importance of muscular joint stabilization in natural human movements. Compared to in vivo measurements it is speculated that the predicted force magnitudes are considerably overestimated due to error propagation and still insufficient anatomical models. Thus, increased efforts to improve further the reliability of internal load calculations should be made in the future.     

Acute and definitive management of traumatic osteocutaneous defects of the lower extremity

Twenty-two lower extremity osteocutaneous defects resulting from high-energy trauma were managed from the onset of injury to rehabilitation by a collaborative effort between orthopedic and plastic surgeons. Emergency debridement of devitalized soft tissue and bone, external fracture stabilization, and serial debridements prepared the wound for closure with predominantly free-muscle transfers performed an average of 17 days (range 3 to 43 days) after injury. Cancellous or vascularized fibula grafting, depending on defect size, was performed an average of 9 weeks (range 6 to 16 weeks) after muscle flap closure. In this group of patients, whose average injury severity score was 18 (range 9 to 45) and whose average segmental bone defect was 8 cm (range 3 to 18 cm), the average time after injury to full weight bearing was 61 weeks (range 39 to 120 weeks). The early infection rate was 14 percent. Two extremities were amputated. There have been no chronic infections. Follow-up has ranged from 9 to 34 months.