The early diagnosis of vertebral artery dissection remains a formidable task. Angiography is the gold standard for diagnosis but, recently, duplex scanning has been used as a non‐invasive screening study1,2. The overall prognosis of such dissection is good, but stenosis or thrombosis of the extracranial vertebral artery can result in brainstem or spinal cord infarction.

A total of 30 040 pregnancies were reviewed at one institution over 5 years to determine the incidence of venous thrombotic complications. Thirty-one patients experienced such complications related to pregnancy (incidence 0.1%); 13 had deep venous thrombosis and 14 had superficial venous thrombophlebitis diagnosed by duplex ultrasound. Four had pelvic vein thrombophlebitis diagnosed by computed tomography scan; three patients (one from each group) sustained a non-fatal pulmonary embolus. Of those with deep venous thrombosis, 10 (77%) were left-sided, and three (23%) were right-sided. Three had a prior history of deep venous thrombosis and one of pulmonary embolism. Of those with superficial venous thrombophlebitis, seven (50%) were left-sided, six (43%) were right-sided, and one (7%) was bilateral. Most with deep venous thrombosis presented later in pregnancy; three in the first trimester, two in the second, three in the third, and five early postpartum. Most (1014) with superficial venous thrombophlebitis presented within 48 hours of delivery. Distribution of thrombi in those with deep venous thrombosis was compared with 643 non-pregnant women with a similar condition. A pattern of proximal involvement on the left was found, with left common femoral vein (54% versus 28%, P = 0.03) and superficial femoral vein (62% versus 26%, P = 0.006) more often involved in pregnant patients. The average number of vein segments involved was greater on the left than the right (5.3 versus 3.7). Symptoms of chronic venous insufficiency developed in three with deep venous thrombosis (25%) and in three with superficial venous thrombophlebitis (27%). None had recurrence of deep venous thrombosis. It is concluded that venous thrombotic complications associated with pregnancy are not necessarily benign, with the risk of pulmonary embolism and chronic venous insufficiency not limited to patients with deep venous thrombosis only. Copyright © 1996 The International Society for Cardiovascular Surgery.

A 70-year-old woman underwent an elective sigmoid resection for chronic diverticulitis. On the third postoperative day she suddenly developed abdominal pain and hypotension after a coughing episode. Radiologic evaluation demonstrated the presence of a hemoperitoneum. A celiac arteriogram was obtained in an effort to determine the cause of the hemorrhage. Four aneurysms of the intrahepatic portions of the left and right hepatic arteries were found. These aneurysms were successfully treated using steel coil embolization. Surgery has traditionally been the “gold standard” treatment of this rare entity. Recent reports have demonstrated the utillity of embolization in treating aneurysms of the hepatic arteries. This report reviews the current treatment options available in the management of hepatic artery aneurysms. Embolization of the aneurysms is recommended.

Virchow's triad of venous stasis, vessel wall damage, and hypercoagulability cites three factors that predispose to the formation of venous thrombosis. The pneumoperitoneum created during laparoscopic surgery results in an intraabdominal pressure that exceeds the pressure of venous blood return from the legs. This may alter venous hemodynamics enough to result in venous stasis in the legs, thus increasing the risk of thrombus formation. Duplex ultrasound was used to measure the diameter and venous flow volume of the common femoral vein during laparoscopic cholecystectomy. Measurements were obtained at three different times: after induction of anesthesia but prior to creation of pneumoperitoneum, during pneumoperitoneum, and after abdominal deflation but prior to reversal of anesthesia. After insufflation of the abdomen, the mean cross-sectional area of the common femoral vein increased (0.83 to 1.15 cm2; p = 0.0024) and the venous flow decreased (11.00 to 6.06 cm3/sec; p = 0.0008). After deflation of the abdomen, there was no significant change in cross-sectional area of the common femoral vein, but there was an increase in venous flow (6.06 to 9.94 cm3/sec; p = 0.0005). Abdominal insufflation during laparoscopic cholecystectomy results in dilation of and decreased flow in the common femoral vein. After deflation of the abdomen, flow in the vein returns to baseline levels.

BACKGROUND:Currently, there is no consensus in the literature regarding which patients with calf vein thrombi are at high risk for proximal propagation. This study examined patients with isolated calf vein thrombi with serial duplex scans in order to identify risk factors that would predict outcome.PATIENTS AND METHODS:Between May 1989 and November 1994, 288 patients were identified with isolated calf vein thrombi. One hundred ninety-two of them had sequential scans performed.RESULTS:Fifty-three (28%) of the 192 patients had propagation of their initial thrombi. The most proximal level of propagation was the popliteal vein in 11 patients, the superficial femoral vein in 5, the common femoral vein in 5, adjacent tibial or soleal veins in 24, adjacent soleal veins alone in 7, and the lesser saphenous vein in 1. Three patients whose thrombi propagated had free-floating thrombus tips in the large veins of their thighs. Symptoms, prophylaxis, and risk factor analysis comparing those patients whose thrombi propagated to those whose thrombi did not found no statistically significant prognostic value. Single or multiple calf vein thrombi did not predict propagation. Of the 23 patients treated with heparin, only 3 had thrombus propagation. None of these reached the level of the knee (including popliteal vein).CONCLUSIONS:The natural history of distal lower extremity thrombosis does not appear to be as benign as previously believed.

BACKGROUND: Currently, there is no consensus in the literature regarding which patients with calf vein thrombi are at high risk for proximal propagation. This study examined patients with isolated calf vein thrombi with serial duplex scans in order to identify risk factors that would predict outcome.PATIENTS AND METHODS: Between May 1989 and November 1994, 288 patients were identified with isolated calf vein thrombi. One hundred ninety-two of them had sequential scans performed.RESULTS: Fifty-three (28%) of the 192 patients had propagation of their initial thrombi. The most proximal level of propagation was the popliteal vein in 11 patients, the superficial femoral vein in 5, the common femoral vein in 5, adjacent tibial or soleal veins in 24, adjacent soleal veins alone in 7, and the lesser saphenous vein in 1. Three patients whose thrombi propagated had free-floating thrombus tips in the large veins of their thighs. Symptoms, prophylaxis, and risk factor analysis comparing those patients whose thrombi propagated to those whose thrombi did not found no statistically significant prognostic value. Single or multiple calf vein thrombi did not predict propagation. Of the 23 patients treated with heparin, only 3 had thrombus propagation. None of these reached the level of the knee (including popliteal vein).CONCLUSIONS: The natural history of distal lower extremity thrombosis does not appear to be as benign as previously believed.

Purpose: A prospective study was undertaken of all vascular laboratory tests performed by the ''on-call'' technologist during a 3-year time period.Methods: Technologists take call on a rotating basis. All patients evaluated had symptoms. History and risk factor data were collected at the time of patient encounter.Results: Studies were initiated from the emergency department 56% of the time, from inpatient examinations 33% of the time, and from outpatient examinations 11% of the time. Ninety percent (n = 440) of the studies obtained were venous duplex scans (VDS). Fifty-eight percent (257 of 440) of the studies were performed on weekends. Thirty-two percent of the studies resulted in admission of the patient. Of the 440 VDS obtained, 51% (224 of 440) identified some type of disease. Acute deep venous thrombosis (DVT) was diagnosed in 15% (67 of 440), acute superficial venous thrombosis (SVT) in 4% (17 of 440), acute DVT and SVT in 7% (31 of 440), chronic DVT in 4% (17 of 440), chronic SVT in 4% (16 of 440), and chronic DVT and SVT in 1% (3 of 440); 2% (9 of 440) of the DVTs were of indeterminate age. Other diseases were identified in 22% (95 of 440), including popliteal cysts, inguinal lymphadenopathy, and soft tissue edema.Conclusions: Having an ''on-call'' vascular technologist has allowed patients with acute venous thrombosis to be triaged and admitted, if necessary, in a timely fashion. Those patients who have symptoms and a negative VDS result are able to avoid unnecessary hospitalization and treatment. The expense of this service is easily justified by the savings of unnecessary hospital days.

PURPOSE:The purpose of this study was to determine whether laser Doppler skin perfusion pressure (LD-SPP) could accurately predict amputation wound healing.METHODS:We studied a total of 62 limbs in 52 patients (28 men and 24 women) with a mean age of 62.2 years (range 34 to 93 years). From this, 39 limbs underwent major amputation (15 above-the-knee, 24 below-the-knee), and 23 limbs underwent minor amputations (4 transmetatarsal and 19 toes). There were five postoperative deaths, leaving a total of 57 limbs available for analysis.RESULTS:Three of 13 above-knee amputations failed to heal. Twenty-one of 23 below-knee amputations healed. Three of four transmetatarsal amputations failed to heal and eight of 17 toe amputations failed to heal. Binary table analysis showed that an LD-SPP value of 30 mm Hg or greater had a negative predictive value (healing occurred) of 90%. An LD-SPP value of less than 30 mm Hg at the amputation site had a positive predictive value (healing failure) of 75%, (p < 0.001, chi square analysis). For major amputations, negative predictive value was 100%, and positive predictive value was 83%, (p < 0.001). For minor amputations, negative predictive value was 75% and positive predictive value was 66.7%, (p < 0.09).CONCLUSION:These data support the use of the LD-SPP test in the selection of major amputation level consistent with healing in ischemic limbs. Further study of the value of this parameter in the determination of minor amputation wound healing is necessary.

Deep venous thrombosis (DVT) is a great masquerader that cannot be reliably predicted by a patient's symptoms, history, or risk factors. Bilateral lower extremity duplex ultrasonography scans were made of 2,511 patients and analyzed to identify, if possible, a population in which a unilateral study would be appropriate. A total of 1,086 (43%) patients were found to have deep venous thrombosis--742 (30%) unilateral and 344 (14%) bilateral. Of the patients with DVT for whom side-of-symptom information was recorded, 64% had symptoms referable to the involved extremity and 36% had symptoms referable to the contralateral extremity. Of the 362 patients who had asymptomatic lower extremities, 128 (35%) had DVT. Moreover, clots were found in asymptomatic limbs in an additional 263 patients whose contralateral limb was symptomatic. Logistic regression analysis did not reveal combinations of symptoms and risk factors that could predict DVT. If DVT is suspected, the patient should undergo bilateral lower extremity duplex scanning.

Two patients with traumatic retroperitoneal hematomas causing obstructive uropathy required surgical evacuation of the hematoma to relieve the obstruction. Fast recovery of renal function and an instant increase in urine output resulted. The obstruction to the urine outflow by the retroperitoneal hematoma caused near total collapse of the bladder in these patients, which was corrected by angiographic embolization and surgical removal of the hematoma.