Based on controlled clinical trials, vasoactive drugs (pentoxyfylline, naftidrofuryl, buflomedil) and prostanoids (alprostadil, iloprost) are used in symptomatic peripheral arterial occlusive disease: In stage II, vasoactive drugs are prescribed in order to improve leg hyperemia in response to muscular work; in complicated stage II (e.g., non-healing traumatic skin lesions), and in stages III/IV, prostanoids are given in order to increase forefoot skin blood flow. These drugs should only be applied if neither angioplasty nor vascular surgery are recommendable, possible, or successful after complete angiological diagnostic. It should be considered that these substances have a rather limited clinical efficacy in both stage II and stages III/IV and therefore attempts should be made to select patients with a reasonable chance to benefit. These drugs are also not suitable for primary or secondary prophylaxis against the progression of vascular lesions.

Objective: To evaluate the clinical impact of computer-assisted fluorescein perfusography in peripheral arterial occlusive disease (PAOD).Design: Foot and calf skin perfusion was visualised by intravenous fluorescein injection. Fluorescein influx was recorded photographically and converted into functional images of fluorescein appearance times (AT) by means of digital film processing.Setting: Vascular Laboratory of Clinic for Vascular Disease.Materials: 249 patients with PAOD. Among 481 limbs studied, 83 legs presented with patent arteries, 70 with asymptomatic obstructions (Stage I), 170 with claudication (Stage II) and 158 with rest pain and skin lesions (Stage III/IV).Chief outcome measures: Forefoot and calf mean ATs and standard deviations (SD) served as arbitrary measures of regional skin perfusion rates and their homogeneity respectively.Main results: In the control legs, a homogeneous and fast fluorescence appearance was observed (medians at the foot: AT33.4 s, SD 3.6). In stage II disease, AT (39.9 s, SD 5.6) were slightly impaired as compared to limbs with patent arteries or stage I disease (p < 0.01). Ninety-seven out of the 158 legs in stage III(/IV could be managed by conservative therapy. According to fluorescein-perfusography, they did not differ from stage II disease (AT 38.8 s, SD 6.1). Sixty-one limbs were clinically affected by critical ischaemia. They exhibited a markedly delayed and heterogenous fluorescein influx at the foot (AT 77.3 s, SD 26.5, p < 0.01 vs all other groups). Non-fluorescent areas occurred in 53% compared to only 1% of limbs with and without critical ischaemia, respectively. Retrospectively, predictive values of fluorescein perfusography in identifying a critical limb ischaemia (accuracy 93%) were superior to the ankle systolic material pressure determination (accuracy 80%).Conclusions: Fluorescein perfusography seems to be of diagnostic and prognostic use in PAOD in stage III/IV where inflammatory and ischaemic patterns of dye appearance can be distinguished

In two experiments, audio re-recordings of texts transcribed from television newscasts were presented to independent groups, one group in each case hearing a 'bulletin' with original text structures (as broadcast), the other with key stories revised in accord with story-grammar notions and restoring chronological sequence in the narrative. In Experiment 1 the middle item in a three-story bulletin was subjected to text structure manipulation. After hearing the bulletin, subjects were questioned on information in the texts. In Experiment 2, subjects heard two stories with original or restructured text. In addition to being tested for retention they also rated for bias and quality of writing. Text restructuring improved learning in both studies, especially of information central to the main points of stories. In Experiment 2, such text revision also affected judgements of bias without altering assessment of writing quality. It is suggested that attention to assuring more coherent story structures in newscast texts could counter the problems of poor comprehension and perceived bias on the part of audiences which result from current production priorities and practices.

Conventional PTA represents the state of the art method for treating arterial occlusive disease of the leg arteries. Rotational angioplasty is an improvement over conventional PTA in treating long proximal occlusions of the SFA. It can also be used as a second treatment in cases that were primarily unsuccessful with PTA, with an initial success of 59%. Stent implantation is mainly indicated in limb-threatening ischemia. It also permits successful management of an aneurysm as a late and rare complication correlated to PTA. Atherectomy produces better initial success in eccentric stenotic lesions than PTA. It also permits the successful management of obstructive intimal flaps after angioplasty. The new techniques only improve on PTA, if they are used in the differential therapeutic strategy mentioned above.

The mutual effects of systolic ankle arterial pressures, positional manoeuvres, and calf artery occlusions on transcutaneous oxygen partial pressures (tcpO2) were studied in 388 legs of 258 patients with peripheral arterial occlusive disease (PAOD). The tcpO2-vs-perfusion pressure relationship could be satisfactorily fitted by a non-linear regression model deduced from the tcpO2 theory. Flow-insensitive ranges of tcpO2-vs-flow hyperbolas were reduced by both leg lowering and moving the electrode towards proximal measuring sites. Lower tcpO2 values were found in case of occluded compared to patent calf arteries at ankle arterial pressure indices below 0.4. The tcpO2 positional variability increased' with worsening hemodynamic compensation and was most pronounced in critical limb ischaemia (ischaemic rest pain, non-healing ulcerations). According to a retrospective analysis, a critical ischaemia could be assumed if supine and sitting tcpO2-values exceed neither 10 nor 45 mmHg, respectively.

Hemodynamic assessment of aortoiliac occlusive disease is necessary for successful arterial reconstruction of the legs. Various methods have been proposed, and the “pull through” intraarterial pressure measurement method is accepted as the best standard. The pressure readings, however, seemed to depend on the intraluminal position of the catheter. To explain these observations and make a comparison between the Doppler method and the pull through method, we have studied centerline velocity changes at the stenosis throat by Doppler ultrasonography, and axial and lateral pressure gradients by use of pressure transducers mounted 10 mm and 40 mm downstream of short (4 mm) axisymmetric sharp-edged model stenoses having cross-sectional reduced areas of 64%, 84%, 91%, and 96%. Axial manometric pressures measured 10 mm beyond the throat of 84% stenosis were more than twice as high as the lateral pressures. No significant difference was observed between axial and lateral pressures measured 40 mm downstream from the throat. This pressure distribution has important clinical relevance. Mean and peak pressure gradients for both the Doppler method and manometric measurements were compared. Measurements with Doppler method and manometric measurements indicated that mean pressure gradients (r = 0.98; SEE = ± 2.4 mm Hg) correlate better than peak pressure gradients (r = 0.90; SEE = ± 16.5 mm Hg). Doppler gradients were higher than manometer gradients. Overestimation was 13% for mean pressure gradients and ranged from 10% to 150% for peak pressure gradients. Explanation for the difference between mean Doppler and catheter gradient may be the pressure recovery occurring in the relaminarized poststenotic regions. (J Vasc Surg 1992;16:10–6.)

Die konventionelle Angioplastie ist der Standard der Katheterbehandlung der unteren Extremität. Die Rotationsangioplastie ist der konventionellen Angioplastie bei der Behandlung des langen prox. Femoralis-Verschlusses überlegen. Die Stent-Implantation der A. femoropoplitea sollte überwiegend im klin. Stadium III/IV vorgenommen werden. Sie erlaubt die Korrektur des Aneurysmas, einer seltenen Spätkomplikation der Angioplastie. Die Atherektomie zeigt bei den exzentrischen Stenosen bessere morphologische Ergebnisse als die Angioplastie. Sie läßt eine primär wegen Intimasegel gescheiterte Angioplastie noch erfolgreich abschließen. Die neuen Techniken bedeuten nur bei differenziertem Einsatz einen Fortschritt der Katheterbehandlung.

Transcutaneous oximetry (tcPO2) performed during either oxygen inhalation or leg dependency was intra-individually compared in 64 patients suffering from a peripheral arterial occlusive disease, with and without critical limb ischemia. Among the 81 extremities investigated, 29 had a moderate peripheral arterial occlusive disease (6 in stage I, 23 in stage II) and 52 were initially affected by rest pain or ulceration (stage III/IV). Thirty-seven legs out of the latter improved under conservative treatment. In the remaining 15 limbs, vascular surgery or an amputation became necessary. The tcPO2 was measured at the forefoot with the patient in supine and sitting positions while breathing room air and in the supine position while inhaling 100% oxygen. In limbs with a tcPO2 below 15 mm Hg of patients in the supine position breathing room air, leg dependency generally provoked larger tcPO2 increases than oxygen inhalation. This difference between oxygen inhalation while supine and room air breathing leg dependency tcPO2 values exhibited an approximately linear correlation with the resting tcPO2. Responses of tcPO2 to leg dependency and oxygen inhalation seemed to reflect different mechanisms, that is, microvascular flow redistribution and supine perfusion reserve, respectively. The best discrimination of critical limb ischemia was observed for the tcPO2 of patients breathing room air while in the supine position, which was not surpassed by either the oxygen inhalation or the leg dependency test. Satisfactory results were achieved by combining limits for, first, supine (10 mm Hg) and sitting (45 mm Hg) tcPO2, as well as, second, ankle arterial pressure (60 mm Hg) and supine tcPO2 (10 mm Hg).

Bier's method of regional anaesthesia has been proposed to deposite various drugs intravenously distal to an arterial block in legs with severe arterial insufficiency. From the theoretical point of view it is assumed that ischaemic acral skin areas while being cut off the arterial blood supply may still be reached on the venous route. The purpose of this study was to test this hypothesis for different injection techniques using sodium fluorescein as tracer. Measurements were carried out in ten patients with intermitted claudication. After a circulatory arrest according to v. Esmarch had been established a total volume of 100 ml was injected into a peripheral vein at either the calf or foot. In five patients a homogenous fluorescein mixture was prepared prior to the injection (<<cocktail>>-group) whereas the other five received an isolated fraction of 10 ml fluorescein (<<fraction>>-group). Subsequently, the fluorescence distribution at the calf and dorsum of the foot was photographically recorded over a period of 20 minutes and evaluated by means of digital image analysis. Fluorescence rapidly and homogeneously spread over the investigated skin areas including the toes in all five cases of the <<cocktail>>-group. In contrast, a rather delayed and heterogenous fluorescein distribution was observed in the <<fraction>>-group. Furthermore, in two cases no dye could be detected at the digits after 20 minutes. These results have confirmed the hypothesis of RVP provided that all ingredients are dissolved within an adequate amount of fluid prior to injection.

Bier's method of regional anaesthesia has been proposed to deposit various drugs intravenously distal to an arterial block in legs with severe arterial insufficiency. From the theoretical point of view it is assumed that ischaemic acral skin areas while being cut off the arterial blood supply may still be reached on the venous route. The purpose of this study was to test this hypothesis for different injection techniques using sodium fluorescein as tracer. Measurements were carried out in ten patients with intermittend claudication. After a circulatory arrest according to v. Esmarch had been established a total volume of 100 ml was injected into a peripheral vein at either the calf or foot. In five patients a homogenous fluorescein mixture was prepared prior to the injection ("cocktail"-group) whereas the other five received an isolated fraction of 10 ml fluorescein ("fraction"-group). Subsequently, the fluorescence distribution at the calf and dorsum of the foot was photographically recorded over a period of 20 minutes and evaluated by means of digital image analysis. Fluorescence rapidly and homogeneously spread over the investigated skin areas including the toes in all five cases of the "cocktail"-group. In contrast, a rather delayed and heterogenous fluorescein distribution was observed in the "fraction"-group. Furthermore, in two cases no dye could be detected at the digits after 20 minutes. These results have confirmed the hypothesis of RVP provided that all ingredients are dissolved within an adequate amount of fluid prior to injection.

The value of vasodilator drugs for the conservative treatment of peripheral arterial occlusive disease is widely questioned because clinical and experimental studies have shown paradoxical redistribution phenomena of blood flow in disfavour of an already ischemic peripheral circulation. This paper deals with acute effects of intraarterially infused prostaglandin E1 and buflomedil on the overall foot sole perfusion as well as its distribution patterns. Measurements were performed in patients with sufficiently compensated obstructions of the superficial femoral artery by means of dynamic fluorescein angiography. After i.a. infusion in general an increase of the total blood supply to the feet was found. However, in response to this common vasodilator effect in some patients apparently non-perfused circumscribed skin areas occurred which could never be observed under control conditions. With respect to these results the clinical value of vasodilator drugs as well as the meaning of such adverse redistribution phenomena are discussed from a pathophysiological and pharmacodynamical point of view. It is proposed that the therapeutical concept of pharmacological vasodilation should not be rejected in general. However, special attention should be paid to the development of steal effects.

In a pulsatile in vitro flow model with mounted concentric peripheral arterial stenoses, we compared the mean trans-stenotic pressure difference between pre- and poststenotic segment with the Doppler-estimated mean pressure gradient calculated according to the simplified Bernoulli equation applied over an entire stroke cycle. A close linear correlation was found between Doppler-estimated and invasively measured pressure drop values: Y = 1.13X + 0.47 (r = 0.98, SEE = 1.4 mmHg, n = 16). The Doppler-derived overestimation of the invasively measured mean pressure-drop by an average of 16% (absolute values 2.2 +/- 1.7 mmHg) suggests that in this in vitro model a small part of the kinetic energy of the stenotic jet is recovered distal to the poststenotic turbulences. The difference between both methods is so little that the Doppler-estimated mean pressure drop is acceptable in concentric peripheral model arterial stenoses.

Summary A retrospective comparison of the number of specified alcohol‐related discharges deaths from non‐psychiatric hospitals using Hospital Inpatient Enquiry and Hospital Activity Analysis dam for the North East Thames Region for 1982 indicated a discrepancy of 25% in principal diagnoses between these two official data sources. When second, third and fourth diagnostic categories for the same conditions were included, the magnitude of the discrepancy increased substantially. In the North East Thames Region 2,404 discharges/deaths in which alcohol played some role would not have been identified if only principal diagnoses had been examined. In 1983, 447 alcohol‐related discharges/deaths were recorded in Hospital Activity Analysis data from four District Health Authorities in the North East Thames Region which were estimated to have incurred a cost of £401,370. A further 349 discharges/deaths were recorded in which an alcohol‐related problems appeared in a subsidiary diagnostic category and these were estimated to have incurred a cost of £285,018. When facilities for direct surveying are not available. Hospital Activity Analysis data provider more detailed information than Hospital Inpatient Enquiry: data und should be used in preference for collecting information on disease prevalence and costings. Simple standardised computer programmers could be designed to allow for easier access to, and retrieval of information from, this data source.