Thousands of incarcerated people (individuals who have been imprisoned or detained) are treated in Israeli medical centres each year. The custodial authority during their hospital stay is the local police, the Israel Prison Service (IPS), or the Israeli Army. Positioned at the crossroads of security and human rights, the treatment of these patients almost invariably raises major ethical issues. Shackling during hospital stay is associated with physical, mental, and social effects, which inevitably impair treatment.1Cooke CL Understanding incarcerated populations.AORN J. 2002; 75: 568-580Crossref PubMed Google Scholar International guidelines, such as the Mandela Rules,2UN General AssemblyUnited Nations Standard Minimum Rules for the Treatment of Prisoners (the Mandela Rules): resolution / adopted by the General Assembly, January 8, 2016, A/RES/70/175.https://documents-dds-ny.un.org/doc/UNDOC/GEN/N15/443/41/pdf/N1544341.pdf?OpenElementDate accessed: June 20, 2023Google Scholar determine that health-care standards should not differ for incarcerated people and, given that most incarcerated patients do not pose a direct threat,3Joe S Analyzing mass incarceration.Science. 2021; 374: 237Crossref PubMed Scopus (1) Google Scholar unselective shackling is considered a disproportional measure. In this regard, Israeli law states that incarcerated patients should not be shackled, except in selected circumstances for which individual assessment is required (mainly if there is a direct threat of violence or escape).4State of IsraelSection 9A of the Criminal Procedure Law (enforcement powers—arrests).https://www.nevo.co.il/law_html/law01/055_103.htmDate: 1996Date accessed: June 20, 2023Google Scholar Numerous manuscripts have conceptually addressed the ethical, legal, and medical considerations of shackling of incarcerated patients5Robinson M Lavere K Porsa E End the routine shackling of incarcerated inpatients.J Hosp Med. 2021; 16: 376-377Crossref PubMed Scopus (3) Google Scholar, 6Haber LA Erickson HP Ranji SR Ortiz GM Pratt LA Acute care for patients who are incarcerated: a review.JAMA Intern Med. 2019; 179: 1561-1567Crossref PubMed Scopus (20) Google Scholar, 7Jacobsen AP Robledo-Gil T Nahas-Vigon JH Epstein JA Berger ZD Sufrin CB Care for incarcerated patients hospitalized with COVID-19.J Gen Intern Med. 2021; 36: 2094-2099Crossref PubMed Scopus (6) Google Scholar but, to our knowledge, quantitative data on the extent and nature of shackling during hospital stays have never been published. Under the joint auspices of the ethics board of the Israeli Medical Association and the ethics bureau of the Israeli Nurses Association, we undertook a national programme to document the proportion of shackling during the hospital stays of incarcerated individuals in 14 general hospitals that agreed to participate between Jan 1, 2020, and March 31, 2022, including five of the seven tertiary hospitals in Israel. We excluded psychiatric hospitals because they face a unique risk of violence but also possess better expertise to address these risks than general hospitals. Data were collected prospectively at each of the institutions by a respective local investigator who was not involved in the care of patients and acted on behalf of the hospital management. In four hospitals, prospective assessment was not possible, but we managed to collect data retrospectively from administrative records. The retrospective data did not include some baseline data and details on the exact position of the shackles. Five hospitals included both inpatients and outpatients (including emergency room visits) while the other nine logged data on inpatients only. In all cases, documentation was systematically generated. The collected data and analyses were based on hospital visits and not individual patients. A patient might have thus been included more than once if they visited the hospital on separate occasions. With these data, we aimed to trigger public discussion and, subsequently, national reforms. This surveillance programme has been approved by the ethics committee of Shaare Zedek Medical Center (The Hebrew University of Jerusalem, Jerusalem, Israel). A total of 2950 hospital visits of incarcerated individuals were documented during the study period. Patients were shackled in 2812 (95·3%) of these visits (appendix pp 1–2). Patients were accompanied by guards for all visits (n=1078 with available data; 518 [48·1%] with two guards and 442 [41·0%] with three or more guards). When the type of visit was known (n=2849), shackling proportions were similar between outpatient visits (2249 [95·8%] of 2347) and inpatient visits (470 [93·6%] of 502). Outpatients most often had both hands and legs shackled (1752 [87·0%] of 2013 visits with available data; appendix p 1). In at least 258 (51·4%) of the 502 inpatient visits, the patients were shackled to the bed, although this might be an underestimation given that detailed information on the shackling method was absent for some inpatients (appendix p 1). In 155 visits, inpatients were restrained to the bed with two oblique short shackles on an opposite arm and leg, preventing their movement during the hospital stay, representing 79·9% of 194 inpatient visits in which the patient was shackled to the bed and the shackling position was known (appendix p 1). We found no difference in the proportion of patients shackled between children younger than 18 years (77 [95·1%] of 81 visits) and adults (1138 [93·0%] of 1224 visits). However, the proportion was lower for incarcerated patients older than 65 years (38 [80·9%] of 47 visits; estimated common odds ratio 3·3 [95% CI 1·31–7·60] vs incarcerated patients aged ≤65 years, p=0·0058, stratified Fisher's exact test). Shackling proportion was similar between patients who were arrested due to a criminal offence (748 [94·8%] of 789 visits) and those arrested for a security offence (558 [91·0%] of 613 visits). However, data regarding age and arrest background should be interpreted with caution as they were only collected by some hospitals and may thus be subject to selection bias (appendix p 2). Severely impaired mobility for medical reasons was documented in 106 visits, and in 89 (84·0%) of these visits, patients were shackled regardless, including those who had received major surgery, ventilated patients, and those with severe orthopaedic conditions. We documented demands from guards to be present in the operating theatre and during other major medical procedures. To raise public awareness about this problem, we published part of our data locally in a Hebrew language medical journal,8Bar N Naaman E Asa A et al.Cuffing prisoners and detainees in Israeli hospitals—a multi-center study.Harefuah. 2022; 161 (in Hebrew).: 215-220PubMed Google Scholar as well as in social and print media. This information was also distributed by mass communications to physicians and nurses in Israel, with an emphasis on their ethical obligation to intervene. We then proposed a national action plan, which comprised, among other initiatives, meetings with major policy stakeholders including the security bodies, the Israeli Ministries of Justice, Health, and National Security, and members of parliament to discuss shackling protocols and alternative security measures. Through the Nursing Division of the Ministry of Health, we have been successful in encouraging a nationwide change, such that hospitals are now starting to routinely document shackling in a standardised data field in electronic medical records. In extreme cases when the shackling was clearly unnecessary for medical reasons (eg, for patients with amputed legs or other major health conditions), we have appealed to the courts. Additionally, we initiated an innovation competition for physicians, product designers, and engineers to develop technological solutions that ensure security while minimising the use of shackling. Two of the winning solutions are currently under development. While presenting our data before the Internal Security Committee of the Israeli parliament, the IPS commented that the shackling we documented was not in keeping with local regulations and expressed their commitment to make improvements. In parallel with our monitoring and national intervention activities, we found that shackling proportions began to gradually decrease, with a major decrease from June, 2021, when, as a result of our discussions, the IPS issued updated regulations on the shackling of incarcerated people in medical centres (figure). The decrease in shackling reached a minimum of 77 (83·7%) of 92 visits in September, 2021, but then sharply increased in association with the escape of six incarcerated individuals from a prison (not a medical facility) in northern Israel (from Gilboa Prison on Sept 6, 2021), which triggered a public backlash against the security authorities. To the best of our knowledge, this study is the first in English literature to provide quantitative data on the extent of shackling of incarcerated individuals in medical centres. A full discussion on the balance between security and human rights in the hospital setting is beyond the scope of this piece, but can be found elsewhere.9Haber LA Pratt LA Erickson HP Williams BA Shackling in the hospital.J Gen Intern Med. 2022; 37: 1258-1260Crossref PubMed Scopus (3) Google Scholar In brief, these considerations include the right to security and safety on the part of society and medical teams, versus the right of all patients to be treated with dignity. In addition, shackling during a hospital stay poses the possibility of physical injury, such as handcuff neuropathies,10Stone DA Laureno R Handcuff neuropathies.Neurology. 1991; 41: 145-147Crossref PubMed Google Scholar the risk of pulmonary embolism,11Goldhaber SZ Bounameaux H Pulmonary embolism and deep vein thrombosis.Lancet. 2012; 379: 1835-1846Summary Full Text Full Text PDF PubMed Scopus (700) Google Scholar and pressure ulcers.12Haber LA O'Brien M Shackling ulcer: an upper extremity ulcer secondary to handcuffs.J Gen Intern Med. 2021; 362146Crossref Scopus (4) Google Scholar The sight of shackles can also lead to the patients being perceived as dangerous, which can negatively affect the degree of empathy and quality of medical care offered to these patients, which can, in turn, undermine their trust in medical decisions.1Cooke CL Understanding incarcerated populations.AORN J. 2002; 75: 568-580Crossref PubMed Google Scholar, 13Douglas AD Zaidi MY Maatman TK Choi JN Meagher AD Caring for incarcerated patients: can it ever be equal?.J Surg Educ. 2021; 78: e154-e160Crossref PubMed Scopus (6) Google Scholar Immobilisation caused by shackling to the bed, particularly in the commonly used oblique position, is associated with extreme pain and discomfort, which might become intolerable during a prolonged hospital stay. Indeed, in our cohort, several incarcerated individuals refused hospitalisation in favour of returning to prison where they would be free of shackles. The results obtained in our monitoring programme are country-specific. However, similar to Israel, there are other countries that have individual risk assessment-based shackling regulations, such as Australia, New Zealand, and the UK.14Ombudsman South AustraliaOmbudsman investigation into the Department for Correctional Services in relation to the restraining and shackling of prisoners in hospitals.https://www.ombudsman.sa.gov.au/publication-documents/investigation-reports/2012/correctional_services_july_2012.pdfDate: July, 2012Date accessed: June 20, 2023Google Scholar, 15HM Prison and Probation ServicePrevention of escape: external escorts policy framework. Ministry of Justice and HM Prison and Probation Service, UK2023https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1143131/prevention-escape-external-escorts.pdfDate accessed: June 20, 2023Google Scholar Indeed, more than 50 viewpoint manuscripts from a variety of countries have expressed concerns regarding unselective shackling of incarcerated people in hospitals,5Robinson M Lavere K Porsa E End the routine shackling of incarcerated inpatients.J Hosp Med. 2021; 16: 376-377Crossref PubMed Scopus (3) Google Scholar, 6Haber LA Erickson HP Ranji SR Ortiz GM Pratt LA Acute care for patients who are incarcerated: a review.JAMA Intern Med. 2019; 179: 1561-1567Crossref PubMed Scopus (20) Google Scholar, 7Jacobsen AP Robledo-Gil T Nahas-Vigon JH Epstein JA Berger ZD Sufrin CB Care for incarcerated patients hospitalized with COVID-19.J Gen Intern Med. 2021; 36: 2094-2099Crossref PubMed Scopus (6) Google Scholar suggesting that this is a matter that clinicians across the globe find troubling. Despite these concerns, reports dedicated to the health of incarcerated individuals, such as the Health in Prisons European Database surveys, do not have information regarding shackling practices during medical care. With its basis in a national survey, we present an intervention programme with implementation principles geared towards facilitating, as much as possible, the equal and dignified management of incarcerated patients. Since in-hospital shackling of incarcerated individuals seems to be an unresolved issue worldwide, it is paramount for health-care professionals to be familiar with this matter, both in terms of local and international regulations, as well as its medical and ethical aspects. The sharp increase in shackling proportions after the escape of six incarcerated individuals in Israel highlights the unfortunate reality that policy in this area is often driven by so-called knee-jerk politics rather than by evidence. Therefore, embedding of shackling data into electronic medical records is a cornerstone in promoting transparency and accountability. What cannot be measured cannot be improved, and our findings highlight the effectiveness of rigorous documentation to power change. NB and EN contributed equally as co-first authors and collected and analysed data, and wrote the first draft. DTu conceptualised the study, collected data, supervised the study, and reviewed and edited this Correspondence. DR, NW, and TK collected data, supervised the study, and edited this Correspondence. EA, HY, NY, RW, HP, MK, MP-R, DTe, EK, BY, and ZG collected data and edited this Correspondence. All authors had full access to all the data in the study and had final responsibility for the decision to submit for publication. NB and EN accessed and verified the data. We declare no competing interests that are relevant to the content of this Correspondence. There are no financial conflicts of interest or funding sources to disclose. Aggregative data and related documents (including ethics approval) will be made available on reasonable request with publication by contacting the corresponding author. Sensitive data (including internal communications with the security bodies) will not be shared. For their participation in hospital data collection, we thank Yehuda Chowers, Randa Elias, Neta Nir, Rivka Rudensky, Gali Weiss, Yoni Shimon, Tamar Altaraz, Karen Mashiah Zvang, Benny Avisar, Amit Assa, Hagar Mizrachi, David Pereg, Ilana Peterfreund. Eitan Lavon, Leore Cohen Mendel, Lee Goldstein, Yuval Zelkind, Mali Kusha, Iris Dotan, Eduard Ling, Doron Schwartz, Gershon Jidovetski, Clara Rubinshtein, Gila Hyams, and Khalil Namora. We also thank Avinoam Cohen for legal counselling, Steve Spencer for editorial corrections, and Rachel Buchuk for statistical counselling. Download .pdf (.2 MB) Help with pdf files Supplementary appendix

AIMS:To describe the extent of prisoner/detainee cuffing and characterize cuffing methods.BACKGROUND:Thousands of prisoners and detainees receive medical treatment in Israeli hospitals every year. According to the Israeli law, cuffing during hospital stay should be an exceptional measure, to be considered only in cases of real threat of violence or escape, based on individual assessment. There is no documentation of cuffing rates in hospitals.METHODS:A multi-center study in 12 hospitals was performed during 2020-2021. Data were collected prospectively or retrieved retrospectively from security records, when available.RESULTS:A total of 1857 prisoners/detainees were documented, of whom 1794 (96.6%) were cuffed. Of the 241 hospitalized patients, 230 (95.4%) were cuffed. Details regarding cuffing methods were available for 185 hospitalized patients, revealing that at least 63 patients (68% of patients for whom details regarding cuffing to bed were available) were cuffed to the bed with opposite arm and leg in a cross position. Cuffing rates of prisoners under custody of the Prisons Authority, police and the Israeli Defense Forces, were 98.5%, 96.6%, and 83%, respectively. Impaired mobility for medical reasons was documented in 64 cases, of whom 85.9% were cuffed regardless.CONCLUSIONS:Cuffing of prisoners/detainees in Israeli hospitals is performed non-selectively, in violation of the law. During hospitalization, cuffing is usually performed in a cross position, severely impairing mobility. Our findings highlight the need for routine documentation of cuffing due to its medical consequences and the responsibility of medical staff towards patients according to rules of ethics and regulations.

BACKGROUND:The involvement of mitochondria in pathological states, such as neurodegenerative diseases, sepsis, stroke, and cancer, are well documented. Monitoring of nicotinamide adenine dinucleotide (NADH) fluorescence in vivo as an intracellular oxygen indicator was established in 1950 to 1970 by Britton Chance and collaborators. We use a multiparametric monitoring system enabling assessment of tissue vitality. In order to use this technology in clinical practice, the commercial developed device, the CritiView (CRV), is tested in animal models as well as in patients.METHODS AND RESULTS:The new CRV enables the optical monitoring of four different parameters, representing the energy balance of various tissues in vivo. Mitochondrial NADH is measured by surface fluorometry/reflectometry. In addition, tissue microcirculatory blood flow, tissue reflectance and oxygenation are measured as well. The device is tested both in vitro and in vivo in a small animal model and in preliminary clinical trials in patients undergoing vascular or open heart surgery. In patients, the monitoring is started immediately after the insertion of a three-way Foley catheter (urine collection) to the patient and is stopped when the patient is discharged from the operating room. The results show that monitoring the urethral wall vitality provides information in correlation to the surgical procedure performed.

Monitoring of the mitochondrial NADH redox state (an indicator of intracellular oxygen levels) together with microcirculatory blood flow (TBF) and with oxygenation (HbO2) could serve as a preferred approach to evaluate tissue O2 balance or viability. We hypothesize that in the presence of reduced oxygen delivery and extraction, blood flow will be redistributed in order to protect the most vital organs by increasing their regional blood flow, while O2 delivery to the less vital organs will diminish. Thus, the NADH redox state of less vital organs could serve as an indicator of overall O2 imbalance as well as an endpoint of resuscitation. We have therefore developed an optical device embedded in a Foley catheter to provide real-time data on the NADH redox state, TBF and HbO2 in critically ill patients. The CritiView is a computerized optical device that integrates hardware and software in order to provide real-time information of tissue viability [1]. A modified three-way Foley catheter that contains a fiberoptic probe connects the CritiView to the mucosal side of the urethral wall. We have used this device in five female pigs that underwent graded hemorrhage, and in four patients who were monitored during aortic abdominal aneurysm operations. These preliminary swine model and human studies confirm the feasibility of collecting information about mitochondrial function from the urethral wall. The main effects of graded hemorrhage started when the blood volume decreased by 30%. At 40% blood loss, minimal levels of TBF and HbO2 were correlated to the maximal NADH levels. The values of the three parameters returned to baseline after retransfusion of the shed blood. Aortic clamping in patients led to a significant decrease in TBF and HbO2 while NADH levels increased. After aortic declamping, the parameters recovered to normal values. Our preliminary results show that the CritiView may be a useful tool for the detection of O2 imbalance and the development of an emergency metabolic state in nonvital tissues.

We investigated the effect of low-intensity ultrasound (US) on tissue blood flow and angiogenesis after limb ischemia in vivo. Rats underwent surgical ligation of the femoral or the iliac arteries. Half the animals were exposed to low-intensity US (0.05 W/cm(2)) during three consecutive sessions. At 3 weeks postsurgery, limb perfusion was assessed using laser Doppler and angiography. Immunostaining and vascular endothelial growth factor (VEGF) messenger ribonucleic acid (mRNA) expression were performed 7 d postsurgery. US irradiation significantly improved limb perfusion in both ischemic models (p = 0.04). Angiography showed increased blood vessels in the moderate ischemia (p = 0.01), but not in the severe ischemia (p = 0.19). Histology demonstrated a significantly higher number of blood vessels and proliferating cells in US-irradiated moderate and severe ischemia (p = 0.002 and p = 0.03, respectively). VEGF mRNA was significantly higher in moderate ischemia (p = 0.02). No differences in apoptotic cell death were evident in the models. Low-intensity US significantly improved tissue blood flow and angiogenesis, irrespective of the extent of the ischemia.

Background Protruding aortic arch thrombus is associated clinically with life-threatening emboli. Definitive treatment for aortic arch thrombus removal has demanded complicated vascular surgical procedures, with high morbidity and mortality.Methods and results. Transesophageal echocardiography (TEE) enabled diagnosis of a protruding thrombus at the aortic arch in 5 patients, and a simultaneous lesion in the descending aorta in 1 patient. Four patients had visceral emboli, coinciding with peripheral emboli in 2 patients, and the fifth patient had peripheral and cerebral emboli. One patient had had ischemic stroke and femoral emboli a few months previously. Mean patient age was 51 years. None had clinical evidence of coronary or peripheral atherosclerotic occlusive disease. Risk factors included hypertension (n = 2), smoking (n = 4), and preexisting thrombophilia (n = 4). Five patients underwent TEE-guided aortic balloon thrombectomy from the arch with a 34-mm occluding balloon catheter. One patient also underwent balloon thrombectomy from the descending aorta with a 14F Foley catheter. Access into the aorta was obtained through the iliac artery (n = 4) during laparotomy because of visceral ischemia or through the transfemoral approach (n = 2). Previous procedures included superior mesenteric embolectomy (n = 3), segmental bowel resection (n = 1), splenectomy (n = 1), and peripheral arterial embolectomy (n = 3). Real-time intraoperative TEE enabled visualization of the protruding thrombus and assisted with maneuvering of the balloon catheter. At completion peripheral thrombectomy thrombus material was retrieved in 4 patients. Postoperatively there were no clinically proved new procedure-related visceral ernboli, and all patients received anticoagulant therapy thereafter. Follow-up TEE within 2 weeks and up to 7 years revealed no recurrent aortic arch thrombus.Conclusions. TEE-guided aortic balloon thrombectomy used in 6 procedures was effectively completed without visceral or peripheral ischemic complications. It enabled removal of the life-threatening source of emboli from the proximal aorta, thereby averting the need of major aortic surgery.

Surgical intervention failed to stop life-threatening bleeding caused by injury complicated by severe coagulopathy. Administration of recombinant factor VIIa immediately corrected the coagulopathy and bleeding stopped.

The widest application of "damage control" surgery has been in abdominal trauma. The decision to use "bail out" tactics should be made early based on the injury pattern. The major hemostatic techniques are packing, balloon tamponade, and postoperative angiographic embolization. Spillage is controlled by bowel interruption or drainage. Temporary abdominal closure techniques are described.

Background:No information is available on the effects of vasoactive drugs on the microcirculation and on the correlation between their effects on the capillary and the systemic circulation.Purpose:To characterize the effects of nitroglycerin (NTG), nitroprusside (NP), and metaraminol infusion on microcirculatory variables using a noninvasive monitoring system.Methods:Increasing doses of NTG (5–40 μg/kg/min) and NP (5–20 μg/kg/min) were intravenously infused to eight rabbits. The microcirculatory parameters were monitored by a combined noninvasive system which included laser Doppler flowmetry (LDF), photoplethysmograph (PPG), and transcutaneous oxygen tension (tc-PO2). Mean blood pressure (MBP) was measured simultaneously.Results:At maximal rate of NTG infusion, the values of LDF, PPG, tc-PO2, and MBP were 72.2 ± 23.9, 234.7 ± 165.6, 103.5 ± 37.4, and 82.7 ± 7.4% of baseline, respectively. Following NP infusion the LDF, PPG, tc-PO2, and MBP reached 70.8 ± 24.1, 190.5 ± 68.9, 70.0 ± 14.7, and 75.6 ± 14.6% of baseline, respectively. The tissue oxygenation was significantly reduced during NP infusion compared to NTG (P< 0.05). The values gradually returned to the baseline 10 min after termination of NP infusion, but not after NTG. After injection of 1 mg metaraminol there was a steep decline in LDF, PPG, and tc-PO2parallel to a significant increase in MBP. When metaraminol was administered after injection of 0.1 mg phenoxybenzamine, these changes were abolished.Conclusions:This noninvasive system effectively monitors microcirculatory hemodynamic changes induced by vasoactive drugs. NTG and NP cause similar changes in the systemic and microcirculatory bed, with the exception of peripheral oxygenation, which is reduced only during infusion of NP. The changes in the microcirculatory bed following metaraminol and phenoxybenzamine imply that their effects on the arterioles are mediated by adrenegic α-receptors.

Gunshot injuries across the cervical midline are not addressed in existing trauma algorithms. A retrospective study of 41 patients with transcervical gunshot wounds was undertaken to delineate injury patterns and management principles.Thirty-four of the 41 patients (83%) sustained 52 injuries to major cervical structures. Vascular (22 injuries) and upper airway (13 injuries) structures were most commonly involved. This resulted in presentation with life-threatening problems in 16 patients (39%). The in-hospital mortality was 10%.In 30 of the 36 neck explorations (83%), the findings were positive for injuries to cervical structures. Sixteen bilateral explorations were performed; in each case, cervical injury was observed on at least one side of the neck.These results indicate that transcervical injuries are excellent markers of associated visceral injury. Therefore, a policy of mandatory neck exploration and a particularly ''low threshold'' for bilateral exploration are the key to managing these injuries.

The purpose of the study was to examine the ability of a system combining laser Doppler flowmetry (LDF), photoplethysmograph (PPG), and transcutaneous oxygen tension (tc-PO2) to follow changes in the microcirculation during hemorrhage and following blood or saline return, and to test the hypothesis that such changes precede and might predict changes in the systemic blood pressure. Measurements were performed on the skin of anesthetized rabbits (n = 10) during mild (0-8%), moderate (9-24%), and severe (25-30% of blood volume) hemorrhage, and following complete volume restitution by blood or saline. We found the following: 1) hemorrhage caused typical changes in the LDF, PPG, and tc-PO2, signals that could be formulated by mathematical models, 2) these signals identified blood as being more efficient than saline for volume restitution following hemorrhage, and 3) microcirculatory changes precede and might predict systemic hemodynamic events.

Purpose: In an attempt to clarify the role of hypothermic circulatory arrest (HCA) in the management of complex aortic aneurysms operated on through the left thoractomy, our technique of HCA and outcome were reviewed.Methods: During a 21-month period, 15 (17%) of 87 aneurysms of the descending thoracic or thoracoabdominal aorta were operated on by HCA. Eleven patients had chronic aortic dissections (four type A and seven type B), two patients had atherosclerotic aneurysms, and one each had congenital or infected postoperative aneurysms. The use of HCA was planned before surgery in 14 patients. Indications included proximal aortic disease in 12 patients, making either clamping of the transverse aortic arch unsafe (eight patients) or necessitating replacement of the arch with a graft (four patients). Preoperative decision to use HCA was made in two additional patients, one with a ruptured aneurysm and another patient for spinal cord and visceral protection because of anticipated prolonged ischemia as a result of reoperation. Intraoperative technical difficulties prompted the use of HCA in only one patient. Deep hypothermia (15 degrees to 24 degrees C) was induced through partial cardiopulmonary bypass. Left-sided heart venting was necessary in five patients. Aortic replacement was limited to the descending thoracic aorta in five patients, whereas it involved the thoracoabdominal aorta in 10 patients. Four patients had associated replacement of the aortic arch.Results: Three patients died (one of a ruptured aneurysm) during surgery or early after surgery (two of bleeding and one of left ventricular failure). All other patients awoke neurologically intact, but one patient had delayed onset of paraplegia. Another patient died 4 days after surgery of rupture of the ascending aorta. Eleven patients were perioperative survivors without significant morbidity.Conclusions: Hypothermic circulatory arrest is a valuable adjunct in the management of complex aortic aneurysms through left-sided thoractomy. Its results warrant consideration of its selective use for spinal cord/visceral protection.

Low-dose intra-arterial treatment was performed in 124 patients who underwent a total of 142 procedures. The series included 87 occluded arteries and 55 occluded grafts. In only 29 instances (21%) was thrombolysis alone sufficient. In another 77 procedures (54%) the thrombolysis was followed by either angioplasty or minor surgery. In the remaining 36 treatments (25%) lysis of the occlusion failed. A successful end result of combined treatment was achieved in 67 of 77 (87%) procedures. Including the 29 patients in whom thrombolysis alone sufficed, a total of 96 of the 142 procedures (67%) were successful, with the overall success rate being better in grafts (78%) than in arteries (61%). The suprainguinal lesions had a significantly better response compared to the infra-inguinal ones. The evaluation of all procedures was done at the time of discharge from hospital. Complications were related either to local or systemic hemorrhage or distal embolization. Death related to treatment occurred in three patients.

Percutaneous transluminal angioplasty of the infrarenal abdominal aorta (13 patients) and its bifurcation (15 patients) was performed in 28 patients with a total of 32 dilatation procedures. The group consisted of 16 female and 12 male patients and initial successful dilatation was achieved in all. Recurrence within 1 month requiring bypass surgery occurred in 1 patient. Three patients were lost to follow-up. Long-term follow-up in the remaining 24 patients ranged from 1 to 9 years with a mean of 4.5 years. During the follow-up period, repeat angioplasty of the original stenosis was performed in 3 patients and another patient underwent dilatation of a new lesion which developed in the aorta. According to clinical and noninvasive studies, these 4 patients, as well as the other 20, have maintained patency of the treated lesions and are symptom free. No immediate complications requiring surgery occurred. We conclude that angioplasty is the initial treatment of choice in focal lesions of the distal abdominal aorta and its bifurcation.

De Janvier 1979 a Decembre 1991, 174 revascularisations carotidiennes sur 2304 (7,5 %) ont ete realisees chez 166 malades pour une boucle ou plicature stenosante (BPS) de l'artere carotide interne. Le sex ratio etait de 1,4 et l'âge moyen de 66,3 ± 9,6 (38-91) ans. Les malades etaient asymptomatiques dans 17 cas (9,8 %), symptomatiques par accident constitue (AVC) dans 54 cas (31 %) et par accident transitoire (AIT) dans 103 cas (59,2 %) cas. Le territoire symptomatique etait hemispherique dans 108 cas (62,1 %), oculaire dans 19 cas (10,9 %) et vertebrobasilaire dans 30 cas (17,2 %). La BPS etait isolee dans 35 cas (20,1 %) et associee a d'autres lesions dans 139 cas (79,9 %): 119 stenoses atheromateuses, 14 anevrysmes et a lesions stenosantes typiques de dysplasie fibromusculaire

Between January 1979 and December 1991, 174 of a total of 2304 carotid reconstructions (7.5%) were performed in 166 patients for stenotic coiling or kinking of the internal carotid artery. There was a 1.4 male predominance and the mean age of the patients was 66.3 ± 9.6 years (range 38 to 91 years). Seventeen patients (9.8%) were asymptomatic, 54 (31%) were symptomatic because of a previous stroke, and 103 (59.2%) had had transient ischemic attacks. The symptoms were hemispheric in 108 (62.1%) cases, ocular in 19 (10.9%), and vertebrobasilar in 30 (17.2%). The stenotic coiling or kinking was isolated in 35 (20.1%) cases and associated with other lesions of the internal carotid artery in 139 (79.9%). These included 119 atherosclerotic stenoses, 14 aneurysms, and six stenotic lesions due to fibromuscular dysplasia. Angioplasty of the carotid bifurcation was performed in 102 (58.6%) patients, associated with endarterectomy in 84 (48.3%) cases and with dilatation of dysplastic lesions in six (3.5%) cases. A bypass graft and resection and anastomosis of the carotid artery were performed in 36 (20.7%) patients each. There were four postoperative deaths (2.3%): two were due to neurologic causes, one to heart disease, and one to complications of an associated surgical procedure. Five patients (2.9%) had postoperative strokes and eight (4.6%) had transient ischemic attacks. At postoperative follow-up investigations four (2.3%) patients had carotid occlusions and 10 (5.7%) had morphologic abnormalities. At 5 years, actuarial survival was 80.97 ± 8.8%, patency was 96.12 ± 2.95%, and the ipsilateral stroke-free rate was 93.12 ± 4.49%. Treatment of stenotic coiling or kinking of the internal carotid artery yields satisfactory results, comparable to those of endarterectomy, for isolated atherosclerotic carotid stenoses and is effective in the prevention of ipsilateral ischemic stroke.

The present study was undertaken in order to develop numerical criteria for the parameters of laser Doppler flowmetry-skin blood flow velocity and pulse wave amplitude in the evaluation of lower extremity ischemia. Fifty limbs of young healthy volunteers were examined in order to obtain baseline normal values. Patient population was divided into moderately ischemic (52 limbs) and severely ischemic (22 limbs), based on patients' complaints, physical examination, ankle-brachial indices, pulse volume recordings and arteriographies. Univariate comparison between the three groups of skin blood flow velocity and pulse wave amplitude at each time point were done by analysis of variance. Power of discrimination between degrees of ischemia was evaluated by computing sensitivity and specificity, based on skin blood flow velocity and pulse wave amplitude values at time points best for predicting the severity of disease by multiple regression analysis. Using cutoff points of < 31 for skin blood flow velocity and < 9 for pulse wave amplitude, a 96% sensitivity and 96% specificity were obtained in separating normal from ischemic limbs. Cutoff points of < 9 for skin blood flow velocity and < 4 for pulse wave amplitude discriminated with a 100% sensitivity and specificity between the moderately and severely ischemic limbs. We propose the use of laser Doppler flowmetry with local heating and reactive hyperemia, and the cutoff points stated above as an additional tool to evaluate lower extremity ischemia through assessment of cutaneous microcirculation.

Ce travail a ete entrepris pour developper des criteres numeriques d'interpretation des donnees fournies par la debitmetrie Doppler-laser, c'est-a-dire la velocite circulatoire cutanee et l'amplitude pulsatoire, dans l'ischemie des membres inferieurs. Les 50 membres de 25 jeunes volontaires sains ont permis d'etalonner la methode. La population de malades consistait en 52 membres moderement ischemiques et 22 membres severement ischemiques, la severite de l'ischemie etant appreciee sur les symptomes, les signes d'examen, l'index de pression, la plethysmographie et l'arteriographie. Dans les trois groupes de membres les mesures de la velocite circulatoire cutanee et de l'amplitude pulsatoire, pour chaque point de mesure, ont ete comparees de facon univariee a l'aide d'une analyse de variance

Abnormal liver findings on sonography consistent with subcapsular hematoma were seen in a patient prior to clinical and laboratory evidence of preeclampsia and hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome.