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SPECIAL ARTICLE
Practice guidelines: revascularization
Lower extremity
James A. DeWeese, MD, Robert Leather, MD, and John Porter, MD,
Rochester and Albany, N.Y., and Portland, Ore.
Currently in the United States about 100,000 operative surgical
procedures, and probably an equal number of interventional
radiologic procedures, are performed annually for revascularization
of ischemic lower extremities. 1 The need for the majority of these
procedures results from symptoms caused by athero- sclerosis. The
purpose of this document is to present practice guidelines for
lower extremity revasculariza- tion. It is obvious that guidelines
can be neither comprehensive nor exclusive. Deviations from these
guidelines can and should occur when warranted by patient
circumstances. The subjects addressed include indications for
revascularization taking into account the natural history of
untreated lower extremity ischemia, pretreatment evaluation,
methods for treat- ment, care and monitoring during treatment, and
posttreatment follow-up.
INDICATIONS FOR LOWER EXTREMITY REVASCULARIZATION 2,s
Patients requiring lower extremity revasculariza- tion have one
or more well-recognized symptom complexes. In addition to symptoms,
the decision to proceed with treatment is dependent on the presence
of appropriate physical findings, noninvasive testing results, and
lesions demonstrated by imaging tech- niques, as well as a
knowledge of the natural history of the patient before surgery.
From the Division of Cardiothoracic and Vascular Surgery,
University of Rochester Medical Center (Dr. DeWeese), Rochester;
the Department of Surgery, Albany Medical College (Dr. Leather),
Albany; and the Division of Vascular Surgery, University of Oregon
Medical School (Dr. Porter), Portland.
Reprint requests: James A. DeWeese, MD, Division of Cardio-
thoracic and Vascular Surgery, University of Rochester Medical
Center, 601 Elmwood Ave., Rochester, NY 14642.
J VAsc SUING 1993;18:280-94. Copyright 1993 by The Society for
Vascular Surgery and
International Society for Cardiovascular Surgery, North Amer-
ican Chapter.
0741-5214/93/$1.00 + .10 24/9/47174
Symptoms
Chronic ischemia Claudication. Clandication consists of
weakness,
discomfort, or muscular cramping occurring only with exercise
and relieved by a short period of rest. Symptoms typically occur in
muscle groups distal {~ the site of arterial occlusion and may
involve the buttock, thigh, or calf. The pain is caused by failure
of lower extremity blood flow to increase sufficiently to meet the
metabolic demands of exercising muscle, although the pain receptor
pathways are unknown.
Restpain. Rest pain consists of a constant aching discomfort or
burning pain typically occurring in the forefoot. It worsens with
elevation, is lessened by dependency, and is most troublesome at
night. This pain is caused by diminished blood flow that is
inadequate to meet the metabolic demands of resting tissue.
Ischemic ulceration. Failure of minor traumatic lesions to heal
normally leads to painful chronic ulcers that fail to heal because
of reduced blood supply insufficient to meet the increased demands
of healing tissue. Ischemic ulcers also typically occur in the
distal extremity.
Gangrene. Gangrene is characterized by cyanotic, anesthetic
tissue associated with, or progressing
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JOURNAL OF VASCULAR SURGERY Volume 18, Number 2 DeWeese el: aL
281
palpable pulses. Acute ischemia is typically caused by embolic
or thrombotic occlusions of native arteries or previous vascular
reconstruction.
Physical findings associated with lower extremity ischemia
Diminished pulses. Most patients with symp- tomatic lower
extremity ischemia have diminished or absent pulses at one or more
levels in the symptom- atic extremity. Patients with palpable
pulses that disappear with exercise may also have proximal arterial
occlusJive disease. 5
Other physical findings. Other signs of chronic ischemia have
been described including presence of hair loss, thickened nails,
cyanosis, rubor, coolness, pallor, delayed capillary filling,
muscular wasting, and a positive elevation dependency test. The
elevation dependency test consists of elevation of both legs 30
~egrees from the horizontal position for 30 seconds
and then return of the legs to the horizontal position.
Capillary filling and pinkness will return progres- sively from the
heel to the forefoot and finally the great toe. Capillary filling
and venous filling will normally occur within 10 seconds. With the
excep- tion of the elevation dependency test, all of these signs
are sufficiently nonspecific or influenced by environmental
conditions (i.e., temperature) to be of little practical use.
Noninvasive testing 2,3
Physical examination alone is unreliable for com- plete
assessment of lower extremity ischemia. Deter- ruination of
palpable pulse status is not reproducible :and should not be relied
on to assess the presence or severity ofischemia. Objective
noninvasive testing is ~readily available and reliable and should
be a part of l~e preoperative evaluation of all patients with lower
extremity ischemia. The available modalities and
~lications are listed below. Anlde/bractfial systolic arterial
pressures
(ABIs). The highest arterial pressure measured at the ~alkle
with an ultrasonic flow detector divided by the highest arm blood
pressure gives the ABI. The severity of occlusive disease in the
lower extremity is inversely related to the ABI, as is the severity
of symptoms. 6 Resting ABIs of patients considered for therapy are
generally 0.5 or less in patients with incapacitating intermittent
claudication, 0.3 or less in patients with ischemic rest pain, and
0.4 or less in patients with gangrene or tissue loss. This simple
measurement should be performed as part of the physical examination
of all persons suspected of
having lower extremity ischemia. In urgent or emergent cases, or
in occasional patients with typical symptoms and findings, no other
tests may be necessary. Unfortunately the index may- be falsely
elevated in patients with incompressible lower ex- tremity arteries
as occurs in diabetes.
Segmental pressures and Doppler analog waveform recording.
Segmental pressures and Doppler analog waveform recording are most
helpful in localizing the site of obstructive lesions. They are
usually performed at the upper thigh, lower thigh, calf, and ankle.
Doppler waveforms are also obtained from the femoral artery for
evaluation of inflow.
Exercise testing. Treadmill walking with pre- treatment and
postexercise ankle blood pressure provides objective confirmation
of the diagnosis of claudication and allows objective comparison of
pretreatment and posttreatment values for the assess- ment of
results.
Pulse volume recordings. The pulse volume recording is a
calibrated air plethysmographic wave- form recording system test
that is performed at thigh, calf, ankle, metatarsal, mad toe
levels. It provides semiquantitative information of arterial
obstruction. Toe pulse volume recordings and toe pressures are
especially helpful in diabetic patients with relatively
incompressible proximal vessels preventing accurate pressure
measurements.
Duplex scanning. Duplex examinations of the lower extremity
arteries and bypass grafts may localize and quantitate lesions,
differentiate stenoses from occlusions, and measure flow velocities
in bypass grafts.
Imaging examinations Invasive therapy of lower extremity
atherosclero-
sis is based on the segmental nature of the responsible lesions.
Precise localization of lesions to permit procedural planning is
presently possible only through detailed arteriography. In most
cases the arteriograms should include the aorta, lilac, femoral,
popliteal, and tibia/arteries of one or both legs. The pullback
pressure gradient determination during induced reduction in outflow
resistance provides important information on the hemodynmnic
signif- icance of iliac lesions. Well-described angiographic
techniques permit visualization of all vessels that remain patent
even in severely ischemic extremities. 7 It should rarely be
necessary to perform elective arterial surgery for ischemia without
precise arterio- graphic definition of lesions. In the future
detailed duplex examinations and magnetic resonance imag-
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JOURNAL OF VASCULAR SURGERY 282 DeWeese et al. August 1993
ing may provide sufficient detail to replace arteriog- raphy,
but not currently.
Natural history and indications
The natural history of untreated lower extremity ischemia forms
the foundation on which all decisions for treatment are based.
Chronic lower extremity ischemia. Lower ex- tremity arterial
ischemia is a result of stenosis or occlusion of the aortoiliac or
femoropopliteal or tibioperoneal arteries. The occlusion is most
fre- quently the result of atherosclerotic plaque with or without
secondary thrombosis. However, it may also result from emboli,
thrombosis of aneurysms, popliteal entrapment, fibrodysplasia,
adventitial cys- tic disease, spontaneous arterial dissection,
arteritis, radiation, trauma, or Buerger's disease.
Claudieation. Numerous reports have described the generally
benign nature ofclandication indicating the infrequency of disease
progression to amputa- tion. 8,9 Although the impression that
patients with claudication have a benign natural history with
respect to limb loss is widespread, it is probably incorrect. The
"classic" studies that predate the use of modern methods of
objective noninvasive vascular diagnosis (and in fact usually
depended on question- naires) are flawed by inclusion of an unknown
but significant number of patients whose leg pain with walking was
not vascular. The effect is to assign an incorrectly benign
prognosis to the entire patient group. Modern studies of
claudicants in which objective documentation of arterial disease
was required for study entry have clearly shown that the prognosis
for limb loss is related most closely to the severity of disease at
the time of study entry, as assessed by ankle pressure measurements
or other means. The need for amputation or therapy to prevent
amputation occurs annually in 4% to 8% of claudicants followed
prospectively. 9-12
Diabetes mellitus adversely affects the 5-year outcome of the
claudicant and increases the ampu- tation rate as much as
sevenfold. 9 Clinical deteriora- tion with either requirement for
bypass or tissue loss occurred in 35% of those with and 19% of
those without diabetes mellitus.
Smoking also adversely affects the 5-year out- come of patients
with claudication. 9 Worsening of claudication occurred in 31% of
patients who con- tinued smoking compared with 8% of those who
stopped. For claudicants who continued smoking, major amputations
have been required in 11% of cases, compared with 0% for those who
stopped.
The amputation rate is most closely related to severity of
arterial disease as determined by ankle pressure or arteriography
at the time of presentation with claudication. 9,n14 Humphries et
al)0 have shown that sudden severe ischemia occurs in only 11% of
claudicants with isolated aortoiliac occlusion within 4.2 years
(average) of onset of symptoms but was more than twice as likely to
occur in patients with femoropopliteal or multisegmental
disease.
The natural history of claudication argues against arterial
reconstruction for all patients with inter- mittent claudication.
Most claudicants do not have limb-threatening ischemia during 5
years of follow-up.
Cessation of smoking can improve symptoms and decrease the risk
of deterioration. It has also been shown objectively that a walking
exercise program can increase the comfortable walking distance. 1~
On the other hand, the observation that approximate~ 25% of
patients do have deterioration within 5 years emphasizes the
importance of objective follow-up, preferably with noninvasive
testing. This is particu- larly true of patients with diabetes and
continued smoking, because these patients have a four to seven
times greater risk of deterioration. A well-planned elective
operation for the deteriorating extremity is preferable to an
urgent or emergent operation on an acutely ischemic limb. In
addition, there is a variable but small number of patients with
sufficiently severe claudication that they are prevented from
performing tasks required for their livelihood or desired recre-
ational activity. In these instances a revascularization procedure
may be offered to an informed patient who does not have. unduly
significant risk factors or other extenuating circumstances. For
example, if the pa- tient requires a bypass to the tibial level and
has no available saphenous vein, the long-term results of a nonvein
bypass do not justify intervention for patients with only
claudication.
Rest pain, ischemic ulcers, and gangrene. Imminent or actual
tissue loss, particularly in the presence of pain, is the most
frequent indication for lower extremity arterial reconstruction.
Despite risk factors, these patients are generally facing surgery
of one type I or another: arterial reconstruction or
amputation.
Blue toe syndrome. 4 Digital arterial occlusion may result from
in situ thrombosis from many causes such as atherosclerosis,
collagen-vascular arteritis, and Buerger's disease. Alternatively,
it may result from embolization from a proximal cardiac or
arterial~ source, such as a ventricular thrombus, aortic aneu-
rysm, or ulcerated stenotic upstream arterial plaque.
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JOURNAL OF VASCULAR SURGERY Volume 18, Ntmlber 2 DeWeese et aL
283
Management: of the source of the embolus, if extracardiac, is
usually indicated.
Acute lower extremity ischemia. The natural history of acute
lower extremity ischemia is variable, ranging from rapid
spontaneous improvement to progression to tissue death. Factors
favoring a benign prognosis include presence of preexisting
collaterals (i.e., preexisting history of clandication or previous
arterial reconstruction), presence of audible arterial flow by
Doppler at the time of presentation, and absence of neurologic
changes at the time of presen- tation (sensation and normal
movement intact). Factors predicting a more morbid prognosis
include absence of preexisting arterial disease (as in embolic or
traumatic arterial occlusions), absence of detect- able Doppler
signals, presence ofneurologic changes, and presence of muscular
rigidity. In addition to an uncertain natural history with respect
to the threat- ~ned limb, acute lower extremity ischemia is associ-
ated with significant mortality rates (a mean mortal- ity rate of
approximately 25% in the series reviewed by Blalsdell et al. 16
Death was attributable to both the systemic effects of severe limb
ischemia (myonecro- sis, acute renal failure, and multiple organ
system failure) and the serious nature of underlying disease in
persons suffering acute limb ischemia (e.g., severe heart disease,
advanced malignancy, and multiple trauma).16 It is important that
limb-revascularization procedures be: performed early and
expeditiously in the face of deteriorating clinical findings and be
withheld in the face of irreversible ischemic changes.
Asymptomatic disease Abdominal aortic aneurysms. The presence of
an
aneurysm 4 cm in diameter or greater in the presence of
symptomatic aortoiliac occlusive disease is an indication for
aneurysm resection if there are no other overwhelming medical
problems. 17
Peripheral arterial aneurysms. The complications f peripheral
arterial aneurysms including thrombo-
sis, embolization, rupture, and compression of adja- cent
structures are sufficiently frequent to justify their repair when
discovered.
Neoplasms. Limb-sparing surgery for treatment of bulky extremity
rumors may involve resection of critical arteries and veins,
necessitating revasculari- zation.
PREOPERATIVE GENERAL EVALUATION Virtually all studies of
patients with symptomatic
lower extremk T atherosclerosis have reported de- creased life
expectancy compared with symptom-free age-matched control subjects.
The causes of death are
most frequently related to atherosclerosis at other sites, with
myocardial infarction, stroke,and other vascular events (e.g.,
ruptured aneurysm and visceral ischemia) accounting for more than
three fourths of the deaths. 3 The risk of death appears to be
related directly to the severity of lower extremity ischemia,
whether assessed by objective means or severity of symptoms. For
example, the mortality rate at 5 years of follow-up was 13% in a
series of patients with claudication treated nonoperatively ~8 and
20% in a series of claudicants requiring surgery, 19 but it was 52%
in a series of patients requiring surgery for limb salvage 2 and
88% in a group of patients who underwent repeat operations for limb
salvage. 21 These studies and others indicate that the Severity of
the process of systemic atherosclerosis is reflected accurately in
the severity of lower extremity occlusive disease as determined by
objective testing. Identifi- cation of the extent of the systemic
arteriosclerotic process and other risk factors in the preoperative
evaluation of patients being considered for interven- tion is
extremely important.
History A detailed history is important and should include
information concerning coronary artery disease, di- abetes
mellitus, hypertension, chronic obstructive pulmonary disease,
hypercoagulable states, renal disease, strokes, unusual bleeding,
hyperlipemia, and family history of atherosclerosis.
Complete physical examination Special attention should be
directed to the
following. Bilateral arm pressures. Bilateral arm pressures
may identify proximal upper extremity arterial occlu- sions that
have direct effects on the ability to monitor patients' brachial
arterial pressure in the perioperative period or ABIs long term. In
addition, an unsuitable proximal inflow source for an axillofemoral
bypass may be identified.
Peripheral pulses. Determination of the pres- ence and magnitude
of peripheral pulses is helpful in the identification of the site
of arterial occlusions, as well as for long-term monitoring.
Aneurysm. It is important to identify aortic or peripheral
aneurysms as sources of emboli and for appropriate management by
either operation or observation.
Bruits in the neck, abdomen, or groin. Bruits may identify
stenotic lesions that require further evaluation.
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JOURNAL OF VASCULAR SURGERY 284 DeWeese et al. August 1993
Laboratory testing
Routine testing Blood tests. Appropriate preoperative
laboratory
testing includes determination of a complete blood count
including a platelet count, prothrombin time, and partial
thromboplastin time. A biochem- ical profile should include blood
urea nitrogen, serum creatinine, serum cholesterol, and
triglyceride levels.
Other. A routine urinalysis, chest x-ray, and electrocardiogram
are recommended.
Special as indicated Coronary artery disease. Coronary artery
disease is
present in at least 70% of patients with symptomatic lower
extremity vascular disease, of which approxi- mately 20% is severe
enough to warrant coronary revascularization. 22,23 Furthermore, it
is the most frequent cause of death during the early and late
follow-up of patients who undergo surgery. The mortality rate from
coronary artery disease for patients who undergo arterial
reconstruction in collected series is approximately 15% at 5 years,
25% at 10 years, and 35% at 15 years. 19,24'2s In addition, the
10-year mortality rate for patients with and without known coronary
artery disease who undergo surgery has been in the range of 69% to
92% versus 26% to 65%. 19'2~'26 Available data do not currently
permit an objective documentation of the benefits of prophylactic
coronary bypass in this patient group for prolongation of life.
However, physicians caring for patients with symptomatic lower
extremity athero- sclerosis must be concerned about coronary artery
disease primarily because of its adverse effect on perioperative
death and morbidity. 273 Significant symptoms include unstable
angina pectoris, severe congestive heart failure and controlled
arrhythmia, and recent myocardial infarction. In such patients any
of the detailed preoperative tests listed below may be appropriate
before performance of lower extremity revascularization.3133
Exercise stress electrocardiogram Exercise thallium cardiac scan
Intravenous dipyridamole or adenosine thallium
scan Multigated cardiac blood pool scan Long-term Holter monitor
for evidence of silent
ischemia Cardiac catheterization with coronary arteri-
ography Therapeutic alterations resulting from such diag-
nostic information may include a decision to choose nonoperative
treatment of lower extremity ischemia
or employ a procedure of lesser magnitude, such as
axillary-bifemoral bypass instead of aortobifemoral bypass.
Specific cardiac treatment before lower ex- tremity
revascularization may include alteration of medications or fluid
balance. Other treatments may include pacemaker insertion and
coronary artery bypass grafting. 23,34,3s Numerous ongoing studies
are attempting to define precisely the group of symptom- free
patients who will most benefit by such detailed preoperative
coronary studies. Clearly, extension of these expensive and
frequently invasive diagnostic procedures to all patients
undergoing vascular sur- gery presently appears unwarranted.
Carotid artery disease. Widespread performance of carotid artery
duplex scanning has resulted in defini- tion of categories of
stroke risk associated with varying degrees of carotid artery
stenosis. Many believe that asymptomatic internal carotid artery
stenosis of greater than 70% to 75% diamete, ~ reduction has a
sufficiently high risk of stroke to justify prophylactic carotid
endarterectomy? 6-s8 At least one study suggests that the risk of
perioperative stroke in patients with severe carotid stenosis is
significant, 39 although the incidence of stroke in patients with
hemodynamically significant carotid stenosis in multiple other
studies was not different from that found in patients without
carotid stenosis. 4-42 It is known that 5% to 8% of patients being
considered for cardiovascular surgery have carotid artery stenosis
of greater than 75% diameter reduction. 43 At present no randomized
controlled trials have established the efficacy of treatment of
such lesions in symptom-free patients by prophylactic carotid
endarterectomy for either prevention of perioperative stroke or
long-term stroke.
Endarterectomy for patients both with and with- out symptoms
with 70% to 75% stenosis is logical and preferable treatment before
arterial reconstruc- tion. 38'44 The experience of Freischlag et
al. 4s at ~' Beebe et al. 46 supports the performance of prophy-
lactic endarterectomy on patients with 75% or greater diameter
stenosis when the combined oper- ative morbidity and mortality
rates are less than 3%. Screening of patients scheduled for lower
extremity revascularization to detect critical carotid artery
stenosis should be performed for symptom-free parents with bruits
and all patients with symptoms. Any of the methods listed below may
be used. Carotid artery duplex scanning Oculopneumoplethysmography
Continuous-wave Doppler with spectral analysis
If any of these tests indicate the presence of critical
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JOURNAL OF VASCULAR SURGERY Volume 18, Number 2 DeWees et al.
285
carotid artery stenosis, carotid arteriography may be performed
to confirm the diagnosis.
Abdominal aortic aneurysm. The incidence of abdominal aortic
aneurysm in patients with lower extremity occlusive disease is
approximately 9%. 47 An abdominal ultrasound examination may be
nec- essary in patients in whom the presence or absence of an
aneurysm cannot be determined by abdominal examination because of
the potentially lethal natural history of these aneurysms. Computed
axial tomog- raphy and tho~:acicoabdominal aortography may also be
required for planning of the operation.
Diabetes mdlitus. The incidence of symptomatic lower extremil~
occlusive arterial disease was more than twice as great in diabetic
compared with nondiabetic patients (4.3% vs 2%) in one epidemi-
ologic study. 9 Approximately 16% of patients with claudication
have diabetes. The foot salvage rate 3 ~cars after operation is
only slightly better for nondiabetic compared with diabetic
patients (93% vs 85%). 24 On the other hand, after the onset of
symptoms of arterial insufficiency, the mortality rates at 5 years
for diabetic patients is twice as great as that for nondiabetic
patients (49% vs 23%). 9 It is important, therefore, to establish
the diagnosis of diabetes to determine the long-term benefit of an
operation. Fasting blood glucose levels and glucose tolerance tests
are required if glucosuria is found.
Pulmonary disease. Symptomatic lower extremity arterial
occlusive disease is more common in cigarette smokers than ha
nonsmokers (2.4% vs 1.4%). 9 Of greater importance is the fact that
approximately 80% of patients with symptomatic disease are smok-
ers. 9 Provan et al. 48 found that the 5-year patency rate for
aortofemoral bypass grafts in nonsmokers was 71% and in those who
stopped smoking 77%, compared with 42% for those who continued
smok- ing. Myers et al.49 found patency rates of femo-
~mpliteal grafts at 4 years of 80% for nonsmokers and 61% for
smokers. The 5-year mortality rate tbr patients with symptomatic
disease who continue smoking is approximately 27% compared with 12%
for those who quit. 49 The importance of smoking in decision making
for operations and in the manage- merit of patients operated on is
obvious. In addition to chest x-rays, heavy smokers and patients
with pulmonary symptoms should also be evaluated with arterial
blood gases and pulmonary function tests. These tests should
include vital capacity, maximum .b~'eathing capacity, and forced
expiratory volume in 1 second.
Hypertension. Approximately 23% of patients
with asymptomatic arterial occlusive disease have a history of,
or currently have, hypertension. 9 There are no studies
incriminating hypertension as adversely affecting morbidity or
mortality rates or late graft patency in patients undergoing lower
extremity arterial reconstruction, although hypertension is an
important risk factor for both myocardial infarction and stroke.
False aneurysms are more common in hypertensive patients.
Coagulation abnormalities. All patients undergo- ing surgery for
leg revascularization should undergo preoperative determination of
platelet count, pro- thrombin time, and partial thromboplastin
time. A clinical history of bleeding abnormality, onset of disease
at less than 45 years of age, or a significant abnormality of any
of the three tests warrants detailed coagulation consultation.
It has become clear in recent years that a significant
percentage of patients with either arterial occlusive disease or a
history of recurrent venous thrombosis have detectable
hypercoaguable abnor- malities. Presently all patients with
multiple prior episodes of lower extremity deep vein thrombosis or
a prior failure of arterial reconstruction should undergo a
screening battery of coagulation tests. This should include a
determination of antithrombin Ill, protein C, protein S,
anticardiolipin antibody, lupus anticoagulant, and lipoprotein A.
Abnormalities of any of these screening tests suggests the need for
a coagulation consultation. Donaldson et al. 5 found deficiencies
of antithrombin III, protein C, and protein S and the presence of
either lupuslike anticoagulant activity or heparin-induced platelet
aggregation in 14 of 137 patients undergoing arterial
reconstruction. ~ Thrombosis occurred within 30 days of operation
in 27% of the 14 patients with positive test results and 1.6% of
the 123 patients with normal results.
INTERVENTIONS FOR ARTERIAL DISEASES Arterial reconstruction
Several different surgical procedures are currently used for
lower extremity revascularization. The factors influencing the
choice of procedure are the nature of the lesions producing
ischemia, the severity of ischemia, the urgency of the need for
revascular- ization, the location of the responsible lesions, the
availability of autogenous venous conduit, and the number and
severity of associated medical condi- tions. The most frequently
used procedures are listed below, with a brief description of the
utility of each.
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JOURNAL OF VASCULAR SURGERY 286 DeWeese et al. August 1993
Embolectomy. This is generally the procedure of choice for acute
arterial occlusion with significant symptoms. In patients with
documented emboliza- tion who have symptoms or minimal symptoms of
anticoagulation without operative intervention as advocated by
Blaisdell et al.,16 embolectomy may be appropriate. On occasion,
patients with angiograph- ically proved emboli may be treated with
throm- bolytic agents.S1
Risks associated with emboli are related to (1) the local
ischemic insult, (2) the procedure used to restore circulation, and
(3) recurrence with damage to another organ system. Stratification
of risk with embolectomy has demonstrated a threefold to sev-
enfold increased mortality rate in patients older than 70
years.
In recent years, overall mortality rates from arterial emboli
have been reported in the range of 10% to 30%. Immediate surgical
complications from emboli include amputation, which will be
mandated in 5% to 25% of patients. Compartment syndrome,
myoglobinuria, renal failure, contracture, and persis- tent
ischemic neuropathy may also result, with a probability of
occurrence related to the degree and duration of ischemia. Short-
and long-term preven- tion of recurrent embolization mandates
anticoagu- lation, with risk of wound hematoma and gas-
trointestinal or other hemorrhage. Anticoagulation will reduce the
rate of reembolization from approx- imately 40% to 20%. 52'53
Endarterectomy. The role of endarterectomy is supported in
aortoiliac bifurcation disease, common femoral disease extending to
the deep femoral artery, and limited superficial femoral artery
disease. Results in the aortoiliac system are comparable to those
of bypass grafting with prosthetic materialfi 4 In the
femoropopliteal system some authors have reported results to be
comparable to those of conventional bypass techniques for localized
disease, sS's6 This has not been the experience of most vascular
surgeons. In the reconstruction of tibial arteries, endarterectomy
has little role because of vessel size, rarity of segmental
involvement, and low flow rates leading to a higher rate of
thrombosis, s7
Bypass grafts. Bypass grafting operations may be categorized as
proximal procedures, distal proce- dures, or extraanatomic
procedures. Proximal proce- dures bypass lesions proximal to the
inguinal liga- ment to provide inflow to the common iliac, super-
ficial, or deep femoral artery, whereas distal procedures bypass
those lesions located distal to the common femoral artery.
Extraanatomic procedures
are used in situations in which routing grafts along the normal
course of the arteries is contraindicated, as in the case of
infections, or relatively contraindicated, as in intracavitary
procedures in patients with mul- tiple risk factors. Bypass
techniques have been employed since the later 1940s and are
considered the "gold standard" against which all other varieties of
reconstruction are compared.
Proximal procedures. Aortic bypass for occlusive disease has
been performed with synthetic prostheses since 1957. Proximally,
these may be fashioned end to end or end to side to the native
aorta. End-to-end anastomoses are preferred if the bypassed segment
is aneurysmal, thrombosed, or a source for emboli. End-to-side
anastomoses are employed to ensure flow to arterial branches
proximal to the occluded aorta or iliac arteries. Distally the
graft limbs are anastomosed end to side to the iliac or femoral
artery, ensuring retrograde flow to vessels distal to occlusion.
The distal femoral anastomosis must ensure excellent flow to the
deep femoral artery and may require a profundaplasty.
Results with aortofemoral reconstruction are excellent, with
graft patency rates at 5 years ranging from 80% to 90% and at 10
years from 70% to 75%. s4
Distal procedures. Distal procedures may extend from the common
femoral, superficial femoral, or deep femoral arteries to the
above-knee or below- knee popliteal artery, infrapopliteal
arteries, or arter- ies of the foot.
Results with life-table analysis have been re- viewed
extensively in numerous clinical series. By- passes with autogenous
vein have demonstrated superiority in randomized trials. 5s
Five-year second- ary patency rates in excess of 70% are possible
for reconstructions extending to the popliteal artery and in excess
of 50% for grafts extending to the tibial arteries, s9 The reported
limb salvage rate is 80%~ 90% at 5 years. The greater saphenous
vein is the conduit of choice. Results achieved with other veins
such as the lesser saphenous, arm vein, and superficial femoral
vein are less satisfactory. 6 Results achieved with various
techniques of autogenous grafting, such~ as the in situ saphenous
vein technique and reversed vein technique, have equal success in
randomized trials. 61 Outflow procedures performed with pros-
thetic grafts are justified in some patients requiring above-knee
bypasses if autogenous vein is not avail- able. 5s Some patients
with severe obstructive disease. may require combined inflow and
outflow bypass grafts for reliable salvage of a failing foot.
These
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287
extensive operations are best performed by multiple
simultaneously operating teams. 62
Extraanatomic procedures'. In selected patients, extraanatomic
grafts to restore inflow may be per- formed by femorofemoral,
axillofemoral, axillo- bifemoral, or crossover iliofemoral
technique. Axil- lofemoral bypass for aortoiliac occlusive disease
provides 5-year patency rates of 40% to 70%, which is not as good
as results of aortofemoral and iliofemoral bypass grafting.
54,63"66 However, patency rates of 75% to 80% at 3 to 4 years have
been reported with the use of externally supported axillo-
bifemoral prosthetic grafts. 67 The choice of a cross- over
iliofemoral or femorofemoral bypass as opposed to a unilateral
iliofemoral bypass for an isolated lilac stenosis is stil] being
debated.
Patch angioplasty. For limited atherosclerotic stenoses or
recurrent lesions with neointimal fibrous lyperplasia, patch
angioplasty with or without local- ized endarterectomy may be
indicated. This is used most frequen@ in the lilac, femoral, deep,
and superficial femoral arteries and occasionally in the popliteal
arteuz. In larger arteries, use of prosthetic material for
angioplasty is justified, but for medium- sized arteries, including
the deep popliteal and tibial arteries, autogenous vein or
endarterectomized artery is preferred. Additional use of patch
angioplasty is in the closure of longitudinal arteriotomies made
for such procedures as embolectomy or open-balloon angioplasty.
68
If the angioplasty technique is used for properly selected
lesions, results are comparable to those of vein bypass. The most
frequent site for patch angioplasty is the common femoral-deep
femoral system. There reconstruction patency at 5 years for
patients with daudication exceeds 75%. 69,70 Where the initial
indication for reconstruction is limb salvage, results of
profundaplasty are poorer, with , .year patency rates of 20% to
40%. Nevertheless, because it is a local procedure and leaves the
patient with many furore options for reconstruction, it remains an
attractive procedure for the inital man- agement of selected
patients with rest pain or small ischemic ulcers with poor runoff
vessels or a lack of available suitable veins.
Transluminal aJ~erial reconstruction
In 1992 surgical interventions were comple- mented by several
interventional radiographic tech- niques, one of which is generally
accepted (percuta- neous transluminal angioplasty [PTA] with a bal-
loon) and some of which must still be considered
experimental (atherectomy and stenting of angio- plasty sites).
Results of surgery must be compared with those for other
interventions in terms of benefits and risks.
The choice of PTA is affected by the level of the arterial
lesion: patency rates of iliac angioplasty are generally superior
to those of femoral artery angio- plasF. Precise analysis of data
pertaining to PTA is difficult because (1) many early reports did
not use criteria for patency comparable to those customarily used
for vascular reconstructions, (2) many reports omitted standard
life-table analysis, (3) many reports confused primary and
secondary patency (i.e., the effect of a redilation), and (4) many
reports did not inch:de the effect of initial dilation failure in
the calculation of results. Nevertheless, available data support
the following positions.
For segmental common iliac lesions, the initial patency rate
with PTA ranges from 90% to 95%. 7: The 5-year patency rate for
common lilac PTA ranges from approximately 80% for single stenotic
lesions to 50% to 60% in the presence of a diffusely diseased iliac
artery. Percutaneous transluminal angioplasty of external iliac
occlusions is initially successful in 70% to 90% of cases, with a
4-year patency rate ranging from 47% to 86%, all dependent on the
length of the ocdusion.71, 72
In femoropopliteal disease PTA is initially suc- cessful in
about 80% ofstenoses and 75% to 85% of occlusions treated. 7a
Immediate patency depends on the length of the lesion, with patency
rates approach- ing 70% at 5 years reported in the most favorable
CaSeS 72,73
The data regarding the restenosis rate requiring redilatation
are unclear at present. It is generally accepted that redilation is
possible for most lesions (63% in the lilac system and 47% in the
femo- ropopliteal system). 74,7s
If an experienced interventional angiographer trained to perform
transturninal arterial reconstruc- tions is available, balloon
angioplasty ofiliac stenoses and short occlusions is appropriate
for selected lesions. Percutaneous transluminal angioplasty in the
infraingulnal vessels demands more technical skill but may be
appropriate for selected lesions. The choice of balloon angioplasty
versus surgery should be made with mutual consultation between the
interventional angiographer and the vascular surgeon caring for the
patient. 76
Laser-assisted balloon angioplasty has been gen- erally
abandoned. Intravascular stenting and atherec- tomy are procedures
still under development and
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JOURNAL OF VASCULAR SURGERY 288 DeWeese et al. August 1993
study for their clinical efficacy, long-term results, and
cost-effectiveness. As such, their use may be appro- priate for
selected lesions, but these procedures should be applied only when
careful follow-up procedures are in place to evaluate the long-term
results. 76
Nonarterial operations
Lumbar sympathectomy. A major indication for sympathectomy is in
the management of reflex sympathetic dystrophy. In addition it may
be used as an adjunct for the management of atheroembolism of the
foot.
Lumbar sympathectomy is extremely effective in properly selected
patients. The range of mortality rates from sympathectomy is
probably lower than the older reported 0% to 6%. 77 The most
serious local complications are postsympathectomy neuralgia, which
may occur in as many as 50% of patients, and ejaculatory
dysfunction, which occurs in 25% to 50% of patients. If the
indication for sympathectomy is severe, nonreconstructible
occlusive disease with limited tissue loss, healing will result
only in approx- imately half of cases. Considering the natural
history of such wounds, these results are equal to those obtained
with careful wound care and administration of analgesics.
Nevertheless, after a trial of proper wound care, if the risk of
the procedure appears low, sympathectomy may be indicated in
carefully selected patients, particularly those who show objective
evidence of vasospasm.
Fasciotomy. Fasciotomy is indicated when there is direct
evidence for development of a compartment syndrome after ischemia.
This is an adjunctive procedure rather than a primary
reconstruction technique. Results will vary with the indications.
If used for documented compartment syndrome, re- sults will be
related to the degree and duration of ischemia.
Amputation. Primary amputation without an attempt at vascular
reconstruction of a severely ischemia extremity should be uncommon.
Of course primary amputation is a necessary option in the
management of severe diabetic foot infections or in the presence of
gangrene to a degree such that there is not enough viable tissue to
~llow salvage of a functional foot for walking. Primary amputation
may be indicated also in severe ischemia where the physical status
of the patient will never allow useful walking or pivoting for
transfer with the salvaged foot.
The mortality rate with major amputation is high,
ranging up to 30% in collected series. 7ss The risk is high
because of patient selection: the majority of patients with a
threatened limb are candidates for arterial reconstruction after
which limb salvage will be achieved. Most patients who are not
candidates for reconstruction have severe, debilitating generalized
disease.
Thrombolytic therapy
There are several indications for thrombolysis in the management
of peripheral vascular disease: (1) to restore circulation after
acute arterial occlusion, with hope that a treatable cause for
occlusion will be revealed that may then be treated with balloon
angioplasty or surgery; (2) to restore an acutely thrombosed
reconstruction, which may then be treated with balloon angioplasty
or surgery; (3) to lyse arterial emboli to avoid surgical
embolectom~ and (4) to be used in low doses during surgery as a?5
adjunct to thrombectomy.
Results for the different indications are anecdotal at best.
After acute graft thrombosis, dot lysis has been successful in 20%
to 50% of cases, sl Lysis of clot after arterial embolization has
been successful in as many as 80% of cases. 82 In acute bypass
thrombosis, restoration of patency has been achieved in 20% to 75%
of cases, but some 80% to 91% of these grafts will require an
immediate secondary procedure to treat an underlying lesion that
caused the thrombo- sis. 81 The i2-month graft patency rate after
these secondary procedures is a disappointing 20% to 40%. a3
Thrombolytic therapy has another advantage over catheter
thrombectomy of autogenous vein grafts because of the reduced risk
of myointimal injury. Finally, adjunct thrombolysis in the
operative management of acute occlusion has been reported to be
useful in as many as 75% of cases. 84
Serious complications have been reported with even low-dose
thrombolytic therapy. Hemorrha~ occurs in 8% to 24% of patients
receiving streptoki- naseY Hematomas occur in 6% to 20% of
infusions. Systemic allergic reactions are particularly notable
with streptokinase, occurring in up to 50% of infusions. Death
related to drug administration has occurred in as many as 5% of
infusions, mostly with streptokinase. 84 Urokinase is
preferred.
COMPLICATIONS Wound
Bleeding. Reoperation for hemorrhage is re-~ quired after 1% to
3% of lower extremity reconstruc- tions because of improper
hematosis or coagulation
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JOURNAL OF VASCULAR SURGERY Volume 18, Ntm~ber 2 DeWeese et aL
289
disorder. 8s Significant wound hematomas are best managed by
opening of the incision, evacuation of the hematoma, and reclosure
under sterile condi- tions. Needle aspiration is inadequate and
results in infection.
Edema. Edema occurs in a majority of patients with
infrainffainal revascularization, perhaps 70% at least, and results
primarily from surgical disruption of lymphatics. 86 It tends to be
minor and to resolve in 3 to 4 months. With reoperations,
persistent arterio- venous fistulas with in situ bypass, and prior
deep venous thrombosis, edema may be more severe. A sudden increase
in edema may indicate a new episode of deep venous thrombosis.
Lymphorrhea. Lymphorrhea occurs infre- quently, in less than 5%
of reconstructions. It may pose a risk for infection if prosthetic
material is located within the leaking wound. Initial manage- ment
includes bed rest, local occlusive wound dress- ings, systemic
antibiotics, and prophylaxis against venous thrombosis. If these
measures fall, it may be necessary to explore the wound, suture
affected lymphatics, and reclose the wound carefully. 87 Mea- sures
to prew:nt this complication include careful lymphostasis and the
use of a lateral or medial approach to the groin without disruption
of the primary collection of lymphatics and nodes overlying the
femoral vessels.
Skin necrosis. Skin necrosis occurs in as many as 8% of arterial
reconstructions, a8 It is more common in the presence of diabetes,
redo operations, and where vein har~est requires creation of thin
skin flaps. Management includes local dressings to allow demar-
cation, wound debridement, and the occasional use of skin grafts or
flaps for dosure, s9
Infection. The incidence of infection is approx- imately 1%.
Risk factors include diabetes, redo operations, prosthetic
material, hematoma, pro- _)nged operation, distal sepsis in the
limb, local sepsis in the groin, ongoing bacteremia, lymph
drainage, :skin necrosis, skin flaps, improper closure of wound,
;and puncture site iIffection from angiography.
Thrombosis and thromboembolism
Venous thrombosis. The incidence of clinically significant
venous thrombosis associated with lower extremity revascularization
is remarkably low (i.e., ][%). This has been attributed to the
extensive use of anticoagulants during surgery, which is the period
of greatest venous stasis and greatest risk for develop- rnent of
dots.
Bypass thrombosis. Acute bypass thrombosis
within 30 days is reported in as high as 10% of all
femoropopliteal and femorotibial reconstructions. 9 The incidence
of arterial thrombosis within 1 month of reconstruction for such
procedures as endarterec- tomy and angioplasty is similar.
False aneurysms
False aneurysms occur with an incidence of approximately 1% to
2% in late follow-up.9~ They are attributed to infection, suture
failure, or degenerative change in the host artery with "pull
through" of the suture from the artery wall.
Progressive ischemia, gangrene after bypass
The causes of progressive ischemia after arterial reconstruction
are several.
Hemodynamic failure. Hemodynamic failure occurs when a
reconstruction is patent but delivers inadequate circulation to the
distal extremity. Typical causes include the selection of an
outflow level for the bypass that does not bridge all
hemodynamically significant disease, thrombosis of the outflow
arterial circulation such that the bypass primarily feeds
retrograde into more proximal circulation, or distal occlusive
disease that cannot be bypassed.
Inflow stenosis. When a bypass is placed distal to severe
aortoiliac disease, there may be enough restriction of flow through
the inflow stenosis that, despite a patent graft flow, it is
inadequate to relieve distal ischemia.
Technical problems. Technical problems include stenosis in the
bypass, anastomotic stenosis, im- proper tunneling with
compression, retained clot in the reconstruction, improper valve
incision, intimal flaps, and small bypass diameter. All can lead to
functional bypass failure. 92
Atheroembolism. Microthromboembolic and cholesterol debris may
be released accidentally into the circulation during manipulation
of the arteries causing severe digital ischemia ("trash foot"). The
incidence is ill defined but is probably between 1% and 5%. Initial
management should be watchful waiting with anticipated improvement.
Autoampu- tation of superficial distal digital lesions may occur.
Formal amputation at the most distal level consistent with wound
healing and salvage of fimction may become necessary.
With proper early surveillance, detection, and early
reoperation, these complications can be man- aged successfully.
Progression of ischemia to the point of amputation will occur in
less than 5% of patients.
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JOURNAL OF VASCULAR SURGERY 290 DeWeese et aL August 1993
Major morbidity and death
Pulmonary embolism. The incidence of pulmo- nary embolism after
distal reconstruction is un- known. It is likely less than 1%,
perhaps related to the intraoperative use of anticoagulants.
Stroke. The risk of stroke is low after lower ex- tremity
vascular reconstruction but still four to six times higher than
after general surgery. In symptom- free patients with defined
carotid disease, the risk of stroke is approximately 1%, and in
those with symp- tomatic disease it is increased to approximately
4%, A cervical bruit alone is not a risk factor for stroke,
Myocardial infarction. Approximately 70% of patients who undergo
lower extremity revasculariza- tion have concomitant coronary
artery disease. 22,23 The risk of perioperative myocardial
infarction in patients undergoing vascular surgery is increased by
the presence of a recent myocardial infarction, uncontrollable
angina, pulmonary edema, and ven- tricular dysrhythmias. In the
"best" group of patients the risk is only 4%, but in those with the
worst symptoms morbidity and mortality rates exceed 7% 27,93
Death. Operative mortality rates range from 0% to 7.5% in
various studies, although most indicate a mortality rate less than
3%. The best results are found in series with larger numbers of
patients with claudication, and the worst results typically occur
in patients with limb-threatening ischemia. Diabetes is an added
risk factor.
POSTOPERATIVE FOLLOW-UP OF PATIENTS UNDERGOING LOWER EXTREMITY
REVASCULARIZATION
Appropriate follow-up of patients undergoing lower extremity
revascuiarization is lifelong, in rec- ognition of the chronic
progressive nature of the primary disease process, atherosclerosis.
Ideally this follow-up should be performed by the operating
surgeon. The majority of failures of lower extremity
revascularizations occur within the first year after the procedure.
94 Therefore the number of follow-up visits during this interval
should be greater than during subsequent years. Objective
information con- cerning the patency of arterial repairs, as well
as the status of native arteries in unoperated areas, should be
obtained at every follow-up visit. The results should be subjected
periodically to life-table analysis. 3 Pulse palpation alone is
neither a reproducible nor a reliable indicator of satisfactory
function of arterial repairs. Evaluation of the lower extremity
circulation at follow-up visits can be obtained by noninvasive
means, with the minimum acceptable measurement being an ABI.
Autogenous vein bypass grafts should be exam- ined by duplex
scanning with determination of graft flow velocity. This parameter
has been demonstrated to be a sensitive indicator of impending
graft failure, which becomes abnormal before resting ankle pres-
sure decreases or recurrent patient symptoms occur . 96 The
measurement of ABIs before and after exercise may also uncover
significant stenoses not causing decreased ABIs at rest. Detection
of such impending failure is important because multiple studies
have demonstrated that the outcome of procedures to restore patency
to thrombosed vein grafts is poor with respect to prolonged
patency, 81,95 whereas the outcome of procedures to correct
stenoses in failing grafts before the occurrence of thrombosis is
quite satisfactory. 96,97 Patients suspected of having stenoses in
lower extremity venous bypass grafts shoui~ undergo arteriography
if any of the following find- ings is apparent at the time of
follow-up exami- nation. 97 Recurrent symptoms of ischemia Loss of
previously palpable pulse Decrease in anlde/brachial pressure ratio
of greater
than 0.20 below the highest postoperative value Duplex
scan-determined graft flow velocity less
than 45 cm/sec If arteriograms demonstrate a stenotic lesion
in
autogenous vein bypass grafts of greater than 60% diameter
reduction, elective repair should be per- formed to prevent graft
thrombosis. To date, similar criteria to detect stenoses developing
in prosthetic grafts, or in endarterectomized native arteries, have
not been developed. Ifstenoses are discovered in such
reconstructions, prophylactic reoperation is prudent because of
poor prognosis associated with attempts to restore flow to
thrombosed grafts.
RESOURCES
Operative procedures performed to treat lower extremity ischemia
range in complexity from rela- tively minor procedures such as
femoral embolec- tomy performed under local anesthesia to
extraordi- narily extensive operations on the aorta, iliac, and
femoral arteries involving incisions into major body cavities,
large swings in fluid balance, major blood loss, and many hours of
general anesthesia. Similarly, the severity of illness treated may
range from stable fife-style-limiting claudication in a relatively
healthy middle-aged patient to acute severe limb ischemia occurring
in an elderly patient with severe impair-
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JOURNAL OF VASCULAR SURGERY Volume 18, Number 2 DeWeese et al.
291
ment of cardiac, pulmonary, and renal fimction. Given this
tremendous range in magnitude of proce- dure and severity of
illness, no absolute requirements for patient care and monitoring
can be stated without also describing individual patient
characteristics.
Hospitals and physicians wishing to undertake lower extremi!ty
revascularization must be prepared to care for the entire spectrum
of lower extremity ischemia, however, because the nature of the
primary disease process (i.e,, atherosderosis) implies multi-
system involvement and the potential for major complications in all
patients. Minimal capabilities for performance of lower extremity
revascularization are listed.
Medical staff Given the advanced age and potential for
multi-
system disease, the ready availability of specialists in me
following areas is optimal.
Vascular surgery. Surgeons performing lower extremity
revascularization should be eligible for or possess the Certificate
of Special or Added Qualifi- cations in General Vascular Surgery
issued by the American Board of Surgery or have General Surgical
certification and documented training or experience demonstrating
competence in the performance of vascular surgev.~. 98
Anesthesiology. Qualified specialists in anesthe- siology are
necessary to ensure adequate patient care during operations.
Internal medicine. Complications of lower ex- tremity ischemia
predictably include myocardial in- farction, congestive heart
failure, arrhythmias, car- diogenic shock, renal failure,
respiratory failure, severe soft tissue infections, and septic
shock. Spe- cialists in the following areas are necessary to
provide consultation for optimal patient management: cardi- ology,
nephrology, pulmonary medicine, and infec- , _0us disease.
Critical care. Trained specialists in critical care awe
necessary for optimum patient management. Depending on the
institution, this requirement may be met by the vascular surgeon or
other surgical, medical, or anesthesia physicians.
Radiology. Qualified angiographers with inter- ventional skills
are essential to provide the high- quality arteriograms necessary
for proper procedural planning.
Hospital facilities Intensive care. Capability to provide the
follow-
ing patient care procedures is essential: complete
hemodynamic monitoring including central venous pressure,
arterial pressure, and pulmonary artery pressure with cardiac
output determination; electro- cardiographic monitoring;
respiratory care including respirator support, respiratory
therapists, and blood gas analysis; hemodialysis; and constant
infusion of vasoactive medications.
Operating room. In addition to providing all necessary
instruments for arterial surgery on vessels from the aorta to the
pedal arteries, the operating room must provide capabilities for
patient manage- ment, support, and monitoring equivalent to those
listed under intensive care above. Doppler equipment must be
available immediately. Duplex scarming equipment should also be
available.
Radiology. Facilities for complete operative ar- teriography
including appropriate fluoroscopy and filming equipment and a
complete assortment of catheters, guide wires, and monitoring
equipment should be available.
Inpatient care. Ideally, care of patients undergo- ing vascular
surgery should be concentrated in an identified nursing unit with
nursing staff oriented and skilled in the care of elderly patients
with multisystem disease. Special training in recognition of
cardiac and pulmonary complications and objec- tive assessment of
the peripheral circulation is desir- able. Appropriate equipment
including Doppler flow detectors and pressure cuffs must be
available.
The contributions of J. L. Kaufman, MD, and Lloyd M. Taylor,
Jr., MD, are appreciatively acknowledged.
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Submitted Jan. 5, 1993; accepted March 15, 1993.
SOCIETY FOR VASCULAR SURGERY L IFEL INE FOUNDATION GRANT
AWARD
The Lifeline Foundation of the Society for Vascular Surgery
invites grant applications for funding of meritorious research by
young surgical investigators. The awards are in- tended for
surgeons who have completed their formal surgical education in
general sur- gery and who have completed or are in an advanced
training program in vascular surgery.
To be considered for selection a candidate: 1. Should be
certified by the American Board of Surgery or have completed
the
requirements for certification 2. Should submit an application
within 3 years of completion of an approved resi-
dency training program 3. Must have either a faculty appointment
in an approved medical school in the
United States or Canada or have received an academic appointment
within the guidelines of the applicant's institution
Grant awards are not intended to supplement salary, which will
remai the responsi- bility of the institution in which the awardee
holds an appointment. [[i.e awardee is expected to devote a
significant amount of time to the funded project. A progress3
report will be presented by the investigators during the annual
meeting of the Soci,:ty for Vascular Surgery.
A grant awards committee will review competitive applications.
It is anticipated .daat two grants will be awarded annually
totaling $50,000 each to include indirect costs. Each award will be
for 1 year with the option to extend for an additional year.
Grant appfications may be obtained from: The Lifeline Foundation
Society for Vascular Surgery Thirteen Elm St. Manchester, MA 01944
(508)526-8330
The deadline for receiving applications in the Foundation office
is January 15, 1994. Funds will be awarded by July 1, 1994.