Treatment of Peripheral Vascular Disease: Modern Concepts

Treatment of Peripheral Vascular Disease Modern Concepts ORMAND C. JULIAN, M.D., F.A.C.S. * WILLIAM S. DYE, M.D. t

outstanding developments are responsible for the technical improvements in the treatment of peripheral arterial disease in the past few years. Among these are the greater ease and familiarity with suture technic on major blood vessels, and the special application of anticoagulants in arterial surgery. A more widespread understanding of the emergency nature of acute arterial obstructions, as with embolism and thrombosis, and the realization that they are surgical emergencies has improved management in these conditions. MANY

ARTERIOSCLEROSIS OBLITERANS

Arteriosclerosis is apparently both a degenerative and metabolic disease silOwing tremendous variation in its histopathologic picture, in its rate of development and advancement, and in the manifestations produced in various tissues and organs of the body by the resulting arterial obstruction. The fundamental pathologic feature may be the deposition of cholesterol-like substance in the subintimal vessel layer or destruction and degeneration of the elastic tissues of the vessel, or the deposition of calcium in the media. In many cases there will be seen a mixture of these features, and little of clinical or prognostic value may From the Surgical Service, Veterans Administration Hospital, Hines, Illinois, the Department of Surgery, University of Illinois College of Medicine, and the Chicago Memorial Hospital, Chicago, Illinois. Published with the approval of the Chief Medical Director, Veterans Administration. The statements and conclusions published by the authors are the result of their own study and do not necessarily reflect the opinion or policy of the Veterans Administration.

* Clinical Assistant Professor of Surgery, University of Illinois School of M edicine; Chief of Vascular Surgical Service, Veterans Administration Hospital, Hines, Illinois, and the Chicago Memorial Hospital. t Clinical Instructor in Surgery, University of Illinois College of Medicine; Attending Surgeon, Veterans Administration Hospital, Hines, Illinois, and the Chicago Memorial Hospital. 263

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be derived from learning which kind of arteriosclerosis involves an individual patient. It is of far greater importance to determine the extent and the distribution of the arterial obstructions which ha,ve resulted from the disease. On clinical grounds it is possible to differentiate between three types of distribution of arteriosclerosis in the lower extremities. We have learned to recognize clinically as being significantly different cases in which the primary involvement is diffusely distributed through the small and medium-sized vessels of the extremity; cases in which the involvement is segmental in the large-sized vessels; and cases in which there is a diffuse involvement of large-sized vessels arising at many foci, usually centering about the major branches of the vessels of the extremity. DIFFUSE SMALL VESSEL ARTERIOSCLEROSIS

In the lower extremity diffuse small vessel arteriosclerosis is characterized by very marked evidence of ischemia of the distal parts of the extremity while at the same time there is fairly good major vessel circulation to a point far down in the leg. This may be evidenced by the presence of palpable posterior tibial or dorsal pedal pulsation and by nearly normal oscillometric readings taken at the calf or just below the calf. The lesions responsible for the ischemia are undoubtedly in vessels such as the medial or lateral plantar arteries, the dorsalis pedis artery, or in the digital arteries themselves. These patients also demonstrate a deficient muscle blood supply as well as a deficiency of arterial circulation to the distal end of the foot. They complain of intermittent claudication and night pain of a perfectly characteristic type. This relative muscular ischemia is present in spite of the fact that one can feel a popliteal pulse and demonstrate over the calf oscillometric indices which are not too much depressed. It must be· that in these cases there is a similar small-sized vessel involvement within the body of the muscle and although there is good circulation in the main channels the muscle tissue itself is not receiving adequate blood supply. SEGMENTAL LARGE VESSEL A.RTERIOSCLEROSIS

From the standpoint of development of technic the time is certainly now at hand at which diseased portions of the arterial system will be resected and replaced by new transplanted vessel. Our efforts in this direction have been most encouraging. Some of the details and cases will be mentioned in later paragraphs of this paper. It is therefore tremendously important to recognize patients for whom such direct surgical treatment will be useful. The final diagnosis of a segmental form of arteriosclerosis can, of course, be made only by arteriography. However, certain very definite indications are available in the history and clinical examination of the patient. These patients are usually in a younger age group than the majority of arteriosclerotics. They complain

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ordinarily only of intermittent claudication and intolerance to cold of the lower extremities. The constant pain of ischemic neuritis and the neuritic pain that arises in a nerve accompanying an arteriosclerotic vessel is characteristically absent. The nutrition of the foot is found to be very good. There are no changes in the skin, such as atrophy, fibrosis and pigmentation, and usually no ulcerating lesions unless there is a history of adequate trauma. The pulses will be found to be absent to a strikingly high level. The hallmark of this condition is adequate nutrition of the foot in the absence of pulses even to the level of the external iliac artery. In spite of this obstruction to the main channel of the vessel there may be a small oscillometric index below it. At the time of surgery on these patients, we have found that the retrograde flow from the distal portion of the artery is to some degree pulsatile. The pulse, of course, comes through the unusually well developed collateral arterial bed, and is responsible for the good nutrition in the distal portion of the extremity. These collateral arteries are well shown in the arteriogram in these patients (Fig. 124) and because of their adequacy not only is the proximal extent of the obstruction shown but also the distal segment of the artery fills, giving a complete outline of the lesion. DIFFUSE LARGE VESSEL ARTERIOSCLEROSIS

There can be little doubt but that the diffuse involvement of long segments of the large arteries in the lower extremity with arteri()sclerosis is an outgrowth of an early shorter segment of involvement. We have met with instances in sufficient number, however, in which one· com- . paratively small segment of an otherwise normal vessel is involved that we believe the two types to be significantly different although probably identical in pathogenesis and development. When the large vessels in the lower extremity are diffusely involved, the lesions seem to predominate and become more massive around the major branches. In spite of this, these areas usually are not the points of the greatest obstruction of the lumen, which often occurs some distance away from the branches. The vessel is therefore open in the region in which there is the greatest entrance and exit of the best available collaterals. The arteriogram in cases of this kind will show complete obstruction of a portion of the vessel but in addition the presence of many filling defects which partially occlude the vessel above and below the total obstruction. The newer methods of installing a vein graft to replace the diseased segment are more difficult in this type of involvement because the vessel above and below the obstruction is found to be unsuitable for suture. We have found some promise from an operative technic which may be designated an intimectomy, a method which removes the obstruction and makes it unnecessary to do arterial anastomosis in the diseased portion of the vessel. The details of this procedure will be reported in

,

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later paragraphs. The clinical appearance in cases of diffuse arterial involvement is not particularly characteristic. The degree of ischemia

Fig. 124. Arteriogram of 50 year old male complaining of claudication. Pulses absent below femoral level. Small oscillations present on calf. Roentgenogram shows segmental block of superficial femoral and large number of collateral vessels bridging defect.

of the distal portion of the extremity depends of course upon the extent of the involvement and the efficiency of the collaterals. Diagnosis in detail depends upon arteriogram. Such an x-ray may show a tremendous extent of involvement with only a small degree of obstruction (Fig. 125).

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The abnormal appearance of the artery above and below the obstrudion in such an instance will be diagnostic .

J

Fig. 125. Arteriogram showing diffuse involvement of superficial femoral artery with many filling defects but only a 3 inch segment of total obstruction at the middle of the shaft of femur.

MODES OF THERAPY

Sympathectomy

Lumbar sympathectomy has long been the mainstay in the treatment of the arteriosclerotic extremity. The effectiveness of sympathectomy in any arterial obstructive disease depends upon its ability to abolish reflex vasospasm and to reduce the amount of tone in the peripheral arteries. In arteriosclerosis the former effect, that is of reducing reflex vasospasm,

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is not of great importance because the slow advancing noninflammatory condition does not ordinarily give rise to many vasoconstrictive impulses. The important point at which larger vessel caliber would be beneficial is in the collateral bed which is availahle to by-pass the obstructed area. These collateral vessels, ordinarily free of arteriosclerotic involvement, have the ability to dilate when their sympathetic control is re-. moved. This would indicate that the best candidates for sympathectomy would be those who have segmental large vessel disease, a conclusion which is borne out by clinical experience. The actual selection of patients for sympathectomy depends upon their response to a preliminary sympathetic block with procaine. The skin temperature change after procaine block is not a completely satisfactory index upon which to base a decision concerning s].ugery, but from a practical standpoint is the only one available and in general use. It does not offer any information pertaining to the change in muscle blood flow and cannot be used to judge whether the patient's intermittent claudication will be improved by sympathectomy. Indeed there is no available clinical or experimental procedure which would do so because it would be necessary to measure the muscle blood flow in the unblocked and the blocked extremity at the time of exercise. Some idea as to the efficacy of sympathectomy in intermittent claudication may be obtained by having the patient walk a measured distance before and after his injection to determine the claudication distance at the two times. In those patients who have constant pain of the kind associated with ischemic neuritis it should be noted whether the sympathetic block produces relief. Unfortunately this also is not entirely reliable because there is a good deal of chance for the procaine solution to infiltrate some of the somatic nerve roots in the area which may cloud the results. Resection of lhe Diseased Artery

Resection of the totally obstructed segment in arteriosclerosis obliterans which has been termed arteriectomy has principally been advocated by Leriche,1 who has reported an extensive and favorable experience with this procedure. The purpose of the operation is to remove the irritative source of sensory impulses which are thought to arise in the area of the greatest amount of disease and then reflexly cause vasoconstriction throughout the general area involved. It would seem that this method would be less effective than sympathectomy in producing such an effect. In order to obtain some data on this method, Dr. Philip Shambaugh on the Vascular Surgical Service at Hines Veterans Administration Hospital has done arteriectomy on ten patients most of whom had failed to show a favorable response to sympathetic block and all of whom had painful ischemic extremities. No improvement was noted in the circulation of the extremity. However, for a period varying from a few days to several months, the patients claimed a very

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marked diminution in the pain. We do not know from this data what effect arteriectomy would have in patients with less extensive disease. In our experience arteriectomy has not favorably influenced theprognosis in the cases in which it was used. Resection and Vein Graft

The operation of resection of diseased or damaged vessels and the replacement with a vein graft taken from the same patient has been illustrated diagrammatically in surgical textbooks since the beginning of the twentieth century. Recently Kunlin,2 Fontaine3 and others have reported on their experiences with vein grafts for replacement of diseased segments of arteries. Constant failure had developed a bad reputation for it until recent surgical methods of suture were developed and perhaps more importantly the attention of surgeons has improved blood vessel surgery in general. The recent emphasis and study of the use of preserved blood vessel grafts of homologous type is not important in this particular application because suitable grafts are safely obtained from the patient himself in almost evtlry instance. It is without a doubt desirable to use grafts taken from the same individual and avoid the problem of tissue specificity. With the possible exception of the thoracic and abdominal aorta, replacement of an arterial segment is better accomplished with a vein than with an artery. When an artery is required, as it certainly will be for replacement of the bifurcation of the aorta, it will of course be necessary to use homologous grafts. Much work has been done to determine just how serious the problem of fibrosis and shrinkage will be in homologous arterial grafts. The veins available from the patient himself are the external jugular vein, the superficial femoral vein, and in some cases the saphenous vein. We have used all three with success. It is important to remember, except in the case of the jugular vein, to place the vein in position so that the valves will open with the flow of arterial blood. Both the standard everting continuous and interrupted mattress suture as well as the simple over-and-over suture have been used in anastomosing the artery to the vein. A quicker and better anastomosis has been accomplished in this particular combination of artery, usually somewhat diseased, and vein when the latter type of suture is used. The mattress suture sometimes results in a tendency for the vein to invaginate up into the more rigid artery and for some leakage to occur from a slight scalloping of the vein at those points in which the suture is on the arterial side (Figs. 126 to 129). No greater satisfaction has been encountered in peripheral vascular surgery than to find the peripheral pulses present in an arteriosclerotic leg months after resection and vein graft. This is a procedure which will make the results of sympathectomy in certain selected cases seem very

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Fig. 126.

Fig. 127.

Fig. 126. Preoperative arteriogram showing complete occlusion of the superficial femoral artery just above and extending into the adductor canal. Fig. 127. Postoperative arteriogram. The u~e of smaller caliber vein~'grafts may overcome distention shown in this arteriogram.

Fig. 128. Photograph of opened specimen removed at operation in case shown in Figure 126.

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meager. The replacement of longer and less accessible segments is constantly being attempted. Intimectomy

Soon after beginning the technic of resection and vein grafting a case was encountered in which it was not possible to obtain sufficiently normal artery within a reasonable distance at the proximal end of the obstruction. As had been noted in our previous cases and by others, the cut end of the arteriosclerotic vessel showed a tendency to develop a

Fig. 129. Photograph of step in operation on patient at time circulation was re-established through vein graft. The distention of the vein by arterial pressure is shown.

plane of cleavage between the hardened and fatty central portion and the more elastic normal external portion. By careful blunt dissection this cleavage plane was encouraged and by the simple maneuver of everting the flexible outer layers of the vessel and stripping it back as the hard core was dissected free it was possible to resect, from within, the diseased portion of the artery for a distance of about I! inches. The everted cuff was then returned to its normal position. It was found to lend itself very well to anastomosis to the vein graft. This everting method of removing the diseased portion of the blood vessel, which we have termed an intimectomy, is not new in principle. Dos Santos4 has reported on his technic of "thrombo-endarteriectomy" in which two incisions are made at either end of the diseased segme~t and

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the artery cleared out between. Reboul 6 has advocated a continuous longi tudinal incision over the diseased portion of vessel. Bazy, 6-9 Leriche, l()-l2 Kunlin 13 and Fontaine3 have related their experiences with these methods. The technic of intimectomy alone has been applied to the common iliac artery, the external iliac artery, and to the superficial femoral artery in several cases. In each instance, after obtaining proximal and distal control, the involved artery has been cut across at the center of the obstruction and eversion of the normal external coats carried out in both directions as far as possible. A transverse incision has then been made through approximately one-half of the circumference of the artery at this point, the core drawn through this incision and the same procedure of everting and removal of the thrombus and intima repeated until free flow of blood was obtained. The several transverse incisions were then closed and anastomosis of the divided end of the artery accomplished. Following intimectomy, the interior of the remaining blood carrying cylinder is not by any means ideal, being a wettable, somewhat absorptive and roughened surface. It is without a doubt that complete resection of a diseased segment and replacement by vein graft will be the ideal procedure when possible. Heparinization, preferably by the method of local or regional administration described by Freeman,14 is essential; and as he has pointed out in the cases in which he has done a removal of thrombus and vessel debris, is the only thing that makes this method possible. Freeman has found that the endothelium relines the denuded interior of a reasonably long segment. (Figs. 130 and 131.) Amputation

All other forms of treatment in. degenerative arterial disease are for the purpose of avoiding or limiting the extent of amputation. Little more than a few notes pertaining to amputation will be entered here. Several factors are responsible for a distinct tendency to limit the extent of amputation. The most important factor is the ability of antibiotics to halt the sepsis which, entering through an ischemic toe, formerly doomed many otherwise quite viable legs. Second, the application of. lumbar sympathectomy in conjunction with a minor amputation in an extremity which otherwise would probably require a major one. This combination gives particularly good results in substituting a transmetatarsal amputation for one below the knee, and in healing the amputation wound when only a digit is removed. The third factor is the tremendous reduction of the mortality rate of major amputation from the high levels of ten years ago to one of just over 2 per cent such as we have recorded during the last five years at the Hines Hospital. This relative immunity from fatal disaster encourages one to do a minor amputation even at the risk of having later to do a major one. Choice of anesthesia and the skill of the preoperative and postoperative management outweigh in importance the operative technic of

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amputation. Unilateral spinal anesthesia with hyperbaric anesthesia solution is the method of choice in our hands for major amputations whereas intravenous sodium pentothal anesthesia has been successful for digital amputation. Refrigeration of an ischemic extremity has been employed with benefit preoperatively to stop pain and provide an interval for general preparation for surgery but, in our hands, it has not been necessary to use it as the anesthesia for surgery.

Fig. 130.

Fig. 131.

Fig. 130. Preoperative arteriogram showing absence of the superficial femoral artery from the bifurcation down to Hunter's canal where it is again filled but narrow and irregular. Fig. 131. Postoperative arteriogram showing wide channel six weeks after intimectomy. A filling defect at upper end of superficial femoral artery is very disturbing.

ARTERIOSCLEROSIS IN THE DIABETIC

Histologically there is no very real difference in the vessel pathology in arteriosclerosis of the nondiabetic compared with the diabetic, except that in the latter cases there is a greater tendency for the early deposition of lipoid substances in the subintimal layers of the arteries. Clinically, the two types of cases differ significantly in the comparatively early age of onset of arteriosclerosis in diabetic persons and in the accelerated rate of progression of the lesions. This accelerated course does not appear to be much influenced by the accuracy of the control of the defect in

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glucose metabolism with insulin. The vascular lesion is associated with disturbed lipid metabolism and compares with the development of fatty livers, particularly in the young diabetic. An understanding of the peripheral manifestations of this combination of diseases is very rewarding in its application to individual cases. The so-called foot complications in the diabetic may be divided into those which are principally due to the ischemia of the arteriosclerosis, those due to the lowered resistance to infection of the tissues of the diabetic, and those in which both factors are combined. An accurate evaluation of the relative importance of these factors in each individual case provides a basis for accurate treatment. On examination certain striking differences will be observed between these two types. Although the foot in both instances will display the usual red color of inflammation, the skin in the foot with a high degree of ischemia will be cold, whereas in the foot having lowered resistance there will be heat in normal response to inflammation. The term "cold inflammation" we believe is descriptive of this observation. The erythema of the cold foot disappears when the extremity is elevated, while that of the predominantly infection type remains. The presence of pulses at the popliteal and often at one of the two ankle sites serves to differentiate the two types of foot complications. One must further look for evidences in skin and subcutaneous tissue of long-continued chronic ischemia of arteriosclerosis which will indicate that the etiology is particularly on a vascular basis. The history of intermittent claudication will similarly be evidence of arteriosclerosis. Treatment

The armamentarium in tnerapy of these cases includes antibiotics, incision and drainage, sympathectomy and ampUtation. Penicillin and the other antibiotics must in these cases, as in arteriosclerotics without diabetes, be used in larger amounts than in patients having infection in tissues with normal blood supply. When a fairly adequate circulation apparently justifies an all-out effort to save an infected extremity, the principle of adequate surgical drainage of suppurating areas must be applied. Osteomyelitis, suppurative arthritis, and plantar space infections are the common suppurative lesions in the diabetic foot. Drainage of the osteomyelitic areas with removal of sequestra and often of entire small bones such as the metatarsals will often result in a surprisingly satisfactory foot when antibiotic therapy is carried on adequately and the circulation is good. We have not hesitated to make a radical longitudinal incision along the plantar surface of the foot to drain a plantar abscess, at the same time excising the portions of the plantar fascia which appear to be necrotic. Such incisions often must be accompanied by an amputation of one of the toes

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which has undergone ischemic necrosis due to the combinatIOn of infection and sclerosis of the digital vessels. Sympathectomy has no indication in the acute diabetic foot. It can readily be assumed from the erythematous appearance of the skin that a maximum degree of vasodilatation is already present in response to the infection. Usually in these cases the general condition of the diabetic patient would not permit the easy application of sympathectomy, even if it were considered to be of some benefit. When the infection has been controlled by suitable treatment, as outlined above, a sympathectomy may be used to treat the chronic ischemia if the degree of the response to sympathetic block warrants it. Amputation in the diabetic follows somewhat different criteria as compared to the nondiabetic. When a satisfactory diagnosis of a high degree of ischemia can be made, early amputation will save the patient a great deal of time and expense. Certain practical points are of importance in considering early amputation. Satisfactory evidence in favor of its use is the presence of cold inflammation plus absence of pulses to a relatively high level. The requirements before amputation should be adequate control of the diabetes (this may be difficult), subsidence of the local swelling, and freedom from any signs of infection at the site of the proposed amputation. Elevation of the extremity for the purpose of diminishing the swelling can usually be done without difficulty in diabetics because of the frequent presence of diabetic neuritis of such degree that the lesion in the foot is painless and the added ischemia of elevation does not produce the excruciating pain commonly met with in arteriosclerotics. When pain is present to a degree that prevents elevation, the leg is refrigerated. The refrigeration takes away the pain and the patient is quite comfortable with the leg up. This problem of position in diabetics with originally unilateral leg disease is not only important for the primarily involved leg, but also for the contralateral foot. Occasionally postural edema progresses in the otherwise uninfected leg to the point at which the blood supply is seriously interfered with and involvement of the foot follows. Refrigeration may also be made necessary by severely refractory diabetes in the presence of infection. The diabetic management tends to fall into line immediately after refrigeration of the infected portions of the leg. Usually the only type of amputation that is available after refrigeration is at a supracondylar level. The proximity of the infection and the comparative ischemia of the area makes a leg amputation below the knee impractical. BUERGER'S DISEASE (THROMBOANGIITIS OBLITERANS)

It is with a great deal of hesitancy that any mention of Buerger's disease and its treatment is included in an article boasting, by its title,

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to be modern or to show new trends. At this writing there is no new trend or modern concept to report. The status is, as it was five years ago, one of argument, sometimes scholarly, as to whether sympathectomy is useful in Buerger's patients and, if so, when-it should be applied. Part at least of the reason for this situation is our inability to separate clinically or histologically the variety of arteritic lesions which almost certainly are grouped together under the diagnosis of thromboangiitis obliterans. Some notes on the management of the Buerger's group of diseases are extremely practical and may be made to seem cohesive. Buerger's disease is characterized by acute stages of inflammation separated by periods of remission. Without proper management, however, many of the patients will not get through the first acute stage without some loss of limb. This stage is fundamentally an angiitis involving artery, accompanying vein, and the accompanying nerves. Its manifestations are constant severe pain and the usual manifestations of an inflammation which are somewhat altered by the ischemia. The foot or hand will have the appearance of being involved with a cellulitis but instead of being swollen, red and hot, it will be found to be swollen, red and cool. The redness blanches on elevation and the constant pain of the neuritis will be increased as the ischemia becomes more acute in elevation. Absence of pulses and diminished oscillometric readings are characteristic although the pulses may come and go because much of the arterial insufficiency is due to spasm. Management of the Acute Stage

The only specific treatment of the acute phase of Buerger's disease that is now known is the removal of the etiologic factor of smoking. All other elements of the treatment applied together will seldom produce any effect if the patient continues to smoke even to the slightest degree. The relief of pain in the acute phase is a particularly troublesome and treacherous problem. It is important that the patient have adequate rest and it is also important that he be able to elevate the extremity in order to reduce the edema. At the same time narcotic administration risks addiction because of the prolonged course and the gradual nature of subsidence of the symptoms. Narcotics also reduce the patient's control of his tobacco addiction. A program of pain relief during the night for the purpose of obtaining rest, and planned diversion of the patient's attention during the day should frequently succeed in solving this problem. Nutrition, which is altered by the constant pain, should be carefully watched. Fluid intake, electrolyte intake, and the administration of vitamins are supportive measures. Infection, which is almost invariably present when any degree of open lesions exists, is combated

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by unusually large doses of antibiotics made necessary by the diminished circulation in the infected area. In our experience sympathectomy has not demonstrably altered the course of an acute attack of Buerger's disease. Occasionally the amount of pain may be diminished by sympathectomy and healing of ischemic ulcers appear to follow the performance of the operation. However, if the acute phase is brought to an end without sympathectomy these ulcers will frequently heal anyway. Sensory denervation in cases involving the lower extremity, by crushing the saphenous, superficial peroneal and anterior tibial nerves, is usually disappointing but sometimes results in a spectacular relief. It has in our hands been a prior step toward amputation because the handicap of cutaneous anesthesia is an additional factor too great for the extremity to support. Amputation in the acute phase of Buerger's disease is to be avoided wherever possible because subsidence of this phase may lead to a period of surprising recovery of useful function. It may be made necessary, however, by the duration and severity of the pain and by destructive infection .. Management of the Chronic Phase

As the acute signs of pain, edema and redness gradually subside, signs of improving arterial supply to the extremity become manifest. The blanching on elevation diminishes and some previously absent pulsations may now become faintly palpable. With complete subsidence a true evaluation of the degree of arterial insufficiency with which the patient has been left may be made. This is the phase in which sympathectomy finds its usefulness in Buerger's disease but it must be applied with a full realization of its limitation. The operation does not in any way alter the course of the arteritis, the underlying lesion. Its usefulness is limited to improving the arterial supply to the extremity and should be reserved for those cases in which an improvement is at the time of operation really needed. Good foot hygiene must be taught to patients with a Buerger's history. Protection of the foot from trauma, particularly in patients engaged in shopwork, may be accomplished by the wearing of safety shoes having steel toe-protecting caps. The edict against smoking must constantly be reinforced because a very high rate of recurrence of acute symptoms will follow resumption of smoking. THE SURGICAL MANAGEMENT OF PERIPHERAL ARTERIAL EMBOLI

The appearance of a peripheral arterial embolus constitutes a surgical emergency of the first order, and the removal of emboli from the major peripheral arteries has become an established surgical procedure. With the exception of occlusion of small arteries, neither amenable to surgery nor of danger to an extremity, conservative management alone is rarely

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justifiable. However, in spite of establishment of arteriotomy as a routine procedure involving little risk to the patient and little difficulty with anesthesia, much too frequently the diagnosis of an embolism is not made in time to institute proper surgical treatment. Embolism most commonly occurs in patients with cardiac disease. Rheumatic heart disease with mitral stenosis, arteriosclerotic heart disease, and coronary artery thrombosis are predisposing factors. The clot may come to rest at any point at which the vessel becomes too small to allow further passage, but it is most often found at the bifurcations of the larger arteriel'l, because at these points the diminution in caliber of the vessel is abrupt. As soon as embolic occlusion of an artery occurs, other factors deleterious to the circulation of the extremity come into play. First there is an acute reflex vasoconstriction, involving not only the vessel primarily occluded, but other vessels which under relaxed circumstances might act as collaterals are also thrown into spasm. The second factor is the occurrence of thrombosis of the occluded vessel from the point of embolism downward. The onset of symptoms is rapid and alarming to the patient. The first symptom may be a sudden loss of sensation in the extremity. Usually there is severe cramping pain, but occasionally the loss of sensation is the predominant complaint and pain is secondary. Paralysis of the affected part and decrease in temperature of the skin follow rapidly and are often observed by the patient. Examination shortly after the occurrence will demonstrate a line of skin temperature gradient at the level of circulatory failure. Collateral circulation causes this level to be distal to that of the actual arterial obstruction; thus, in iliac obstruction the skin temperature changes are present well up on the thigh, usually extending higher on the lateral aspect. In the case of the femoral artery, the demarcation in skin temperature occurs just below the knee; popliteal occlusion produces changes distal to the knee. Examination will also show that pulsations are absent below the point of occlusion. Observation of pulsations are in the main a rather unreliable method of determination of level of embolism because the pulse above an embolus may be transmitted by the clot itself, so that the observer will actually feel pulsation below the point of the real obstruction. Application of the oscillometer at various levels on the extremity will aid in diagnosis of the level at which the embolus has lodged, and the fact that an embolus rarely lodges elsewhere than at a bifurcation aids tremendously in the diagnosis of level. There can be little reason for other than surgical treatment of embolism of a major peripheral artery. In areas of adequate collateral circulation necrosis may be prevented by conservative management, but such cases frequently present distressing late residual symptoms of a cool extremity and intermittent claudication. The time limit following embolism during which embolectomy will be of value cannot rigidly be estab-

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lished. The limiting factor is thrombosis of the artery distal to the occlusion. Results as variously reported in the literature show that if embolectomy.is performed within eight hours the results are good and that they deteriorate progressively thereafter. The use of anticoagulants provides a method by which the period of effectiveness of embolectomy may be prolonged, and by which the effectiveness of embolectomy performed at any time may be increased. Immediately following the diagnosis of an acute arterial embolus, 50 to 100 mg. of heparin is given intravenpusly. This dosage has not caused difficulty in closure of the surgical wound made in the involved artery, but it has occasionally caused formation of troublesome hematoma in the wounds. The immediate treatment of a peripheral embolus other than the administration of heparin consists of the use of sympathetic block of the appropriate_ ganglia. Where this has been applied we feel that it has served several purposes. It allows a more accurate determination of the point of obstruction; helps to differentiate other causes of arterial spasm such as thrombophlebitis; and it relieves immediately much of the patient's pain. Surgical approaches to the peripheral arteries considered in this presentation have been made always under local anesthesia and directly over and parallel to the course of the artery at the point of occlusion. On exposure of the artery the embolus is located either by gently palpating it or by noting the point at which the artery is collapsed. A control tape is placed first below the embolus, then control tapes are placed higher on the artery. A longitudinal incision is made in the wall of the artery over or just distal to the embolus. The obstruction is then carefully removed, using a glass suction tip of the largest diameter which will enter the vessel lumen. Both the proximal and distal segments of the artery are aspirated until free bleeding is obtained. Heparin is then instilled in the artery before and after closure. A satisfactory and rapid closure of the artery is accomplished without constriction of the lumen . by using a continuous over-and-over 5-0 silk suture. The removal of the control tapes, first from the distal side of the closure and then proximally, will prevent building up too much pressure on the line of anastomosis. The bleeding points in the wound are ligated carefully because of the anticoagulant therapy which has been begun preoperatively and will be continued afterwards. If pulsations do not return in a short time following removal of the embolus, some consideration must be given to the possibility that a portion of the original embolus broke off at the time of lodgment and went on to become lodged at the next bifurcation. If it can be determined that such has occurred, the fragment should be removed. Anticoagulants postoperatively are continued for seven to ten days. Sympathetic blocks are in some of the cases repeated for two to three days postoperatively. There is, however, danger in doing lumbar blocks on a patient receiving anticoagulants as we have seen a

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large retroperitoneal hematoma form in one case, which was a factor in its fatal outcome. Motion of the extremity and ambulation where possible are probably desirable to prevent stasis, although this may be a questionable procedure where the artery is the site of a severe arteriosclerosis. STASIS DISEASE

The etiologic episode in venous stasis disease is an acute attack of thrombophlebitis, a history of which is almost always recognizable in each patient's history. The importance of perivascular inflammation in producing a secondary obstruction to lymphatic channels has been widely pointed out as an important factor in this condition. Treatment should have its beginning as early as possible in the acute stage of the disease. A number of considerations are vital if the late, disabling manifestations of stasis are to be controlled. The use of anticoagulants in preventing pulmonary embolism in the related condition of phlebothrombosis is well recognized. Anticoagulant therapy in acute thrombophlebitis is of great importance but for a somewhat different purpose-that of limiting the extent to which the clot spreads in the venous system of the leg. Comparative studies on thrombophebitis are difficult to make clinically; it is, however, a very distinct impression that when heparin and Dicumoral are administered the rate of resolution of the thrombophebitic symptoms, particularly of the edema, is accelerated. Loewe15 and de Takats16 have related this to the fact that the fibrinogen in the intracellular edema fluid is less completely converted to fibrin and thus the fluid remains in a more mobile form to be absorbed when the mechanism of its production is gone. Not only is the acute stage materially benefited by this treatment but also the amount of fibrosis with resultant tissue change is minimized in the later course of the disease. The role played by vasospasm in thrombophlebitis has received much attention, particularly by Ochsner. 17- 18 In great part the pain accompanying the acute phase is immediately relieved by a lumbar sympathetic block with procaine. A degree of reflex vasoconstriction may accompany the initial hours of a thrombophlebitis great enough to suggest strongly an acute arterial obstruction. Sympathetic block in such instances will reverse the picture of ischemia, relieve the pain, and make the signs of acute disease manifest. Reflex spasm may be a factor in chronic venous stasis. Certain identifying signs may appear in such cases and will be mentioned later in connection with the use of sympathectomy. The greatest single consideration in the management of the early and the late cases of stasis disease is that of control of edema. No form of management will control the edema in the early acute phase when lymphatic obstruction is added to the venous congestion. Bed rest and elevation with the added use of anticoagulants, antibiotics, and judicious use of heat only gradually reduce the swelling. When the initial edema

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is gone the principal consideration in management should be the prevention of its recurrence. A snail-pace regimen of gradually increasing mobilization in the erect posture is instituted. At first the amount of time in chair, standing and walking which is tolerated without resulting edema may be as little as ten minutes four times each day. Weeks are often required before the patient is able to tolerate exercise without edema so that his rest periods fit in with a gainful occupation. It is essential in such a regimen that the patient understands that the time lost and the pain suffered in the present will be less than if the stasis becomes chronic. Insistence upon this type of management as a primary tool in treatment is particularly important because its use is relatively ineffective after any degree of daily edema has been allowed to persist. The reason for the effectiveness of control of ambulation can be stated only in general terms. There are certainly at least three factors. The first of these is the prevention of fibrosis in the tissues of the extremity which would otherwise result from recurring daily edema. The second is the provision of a favorable medium for the development of the deep venous collaterals. The third is an improvement in the ability for the lymph vascular bed to re-establish itself. It may be contrary to the general principle of prevention of daily edema to provide elastic external support for the extremities for the purpose of lengthening periods of mobility. The question as to whether the pressure of gathering edema fluid in part contained by the external pressure is as bad or worse than edema without support is unanswered. Well wrapped woven rubber and cotton bandages and expertly fitted elastic stockings do increase the patient's comfort and very significantly increase his ability to work. Attention to the construction of the stockings is important. They must extend to the heads of the metatarsals and the heel must be enclosed. Knee length stockings are far more comfortable than garter-supported thigh-length hose. They are less apt to produce constriction at the knee by wrinkling and in the majority of cases are entirely adequate. Complications of Venous Stasis

The late manifestations or complications of venous stasis produce economic problems of some magnitude for patients. The requirements as to treatment are long and expensive and the condition itself is usually incapacitating. Edema and fibrosis of the subcutaneous tissues of the lower leg, fibrosis, atrophy, pigmentation and ulceration of the skin and secondary varicose veins which are produced in part by the attempt to provide collateral venous channels must all be evaluated and treated. The primary requirement is ridding the patient of the edema. Bed rest with elevation and antibiotics to combat the secondary infection almost always present will accomplish this in a reasonably short period of time. The definitive treatment of ulcers and of the secondary varicose veins

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must be considered together. A clue to their close relationship is the relatively constant site of the stasis ulcers on the medial aspect of the lower leg where the ulcerations from primary varicose veins without complicating deep vein disease are most c~mmonly seen. It is at this level that the communicating veins between the saphenous and the deep systems become most effective in transmitting the increased deep venous pressure to the veins draining the skin area while at the same time the greatest degree of superficial vein pressure is encountered due to the incompetence of the valves in the saphenous system. In order to provide a reasonable chance of complete and permanent relief of ulcer formation it is necessary to relieve this area of both sources of pressure and at the same time to remove the severely damaged and scarred skin and subcutaneous tissue. This can be accomplished only by applying adequate surgical treatment. The saphenous system must be removed as completely as possible by ligation, stripping, and excision of varicose masses. Wide excision of the ulcer-bearing area carried out to margins in which the skin is relatively normal, free of fibrosis, and extending in depth to include the deep fascia accomplishes the purpose of removal of communicating channels of veins and at the same time of removal of the damaged and fibrosed tissues. This results in a defect which is often of disturbing proportions both in area and depth. It is sometimes necessary that the defect extend down over the medial malleolus. We have, however, encountered very few failures of healing of split-thickness skin grafts when they are placed in these defects. Disappointments in skin grafting are minimized when the graft is sutured down to the new bed at 1 to 1.5 cm. intervals with fine nonabsorbable sutures and when numerous perforations are made in it to allow for the escape of serum. When healing is complete in these grafts the leg presents an unsightly appearance due to the depression in the area of the graft. Filling in and leveling of the graft sl}rface with that of the surrounding tissue occurs at a rapid rate and progresses in a certain proportion of the cases to a point at which norynal contours are reestablished. Despite the extensiveness of these procedures and the period of postoperative immobility required because of the graft we have not encountered the complication of a recurrence of the deep thrombophlebitis. Success in avoiding recurrence of the ulcer depends upon the patient's self-discipline in the faithful wearing of elastic support and control of the remaining tendency to edema by suitable periods of elevation and on his luck and care in preventing trauma to the grafted site. Sympathectomy in Stasis Disease

In a small proportion of cases sympathectomy has been found effective in diminishing the tendency to edema in patients with residual deep venous obstruction following thrombophlebitis. We have limited the

i"

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application of this form of treatment to those patients who complain of and show persistent coldness and hyperhidrosis of the feet. Lumbar sympathetic block is followed by a significant increase in the comfort of the patient and lumbar sympathectomy subsequently may significantly increase the patient's ability to be up and about without edema. Major Vein Interruption in Stasis Disease

Healing of a severe thrombophlebitis will usually fail to result in the re-establishment of a patent lumen in the femoral venous system. Under certain circumstances, probably depending primarily upon the mildness of the inflammatory portion of the thrombophlebitis, a patent lumen through a thickened vessel may return throughout the leg. This system will then be devoid of valves and being valveless will be less efficient than the available collateral veins in retqrning blood upward in response to muscle activity in the leg. There will then result a tendency for reflux blood flow through the deep veins of the leg producing an increased load on the collateral veins which would appear under these circumstances to be the only efficient venous drainage of the leg in the erect posture. This concept of deep venous reflex was stated by Linton,19-20 who tested the theory by ligation of the superficial femoral vein below the profunda branch in patients with postphlebitic syndrome. He reports improvement in the tendency to edema and diminution in the amount of pain. Following the ligation it is assumed that the improvement in venous return from the leg occurs through collaterals involving the profunda femoris branch. Bauer21 and de Takats22 have advocated ligation of the popliteal vein in these cases to make use of the collateral venous bed around the knee. Although many of these cases may be selected for vein ligation on the basis of the actual demonstration of reflux vein flow by the injection of diodrast into the vein with the patient in the vertical or nearly vertical position, Bauer and de Takats have chosen their patients on the basis of their complaints. Improvement in edema and symptoms has been noted in those patients who complain of the rapid development of a bursting type of pain upon standing up. In following these technics, in an attempt to be cautious in the application of a somewhat contradictory procedure we have chosen those patients in whom the onset of edema upon arising after a period of rest is unusually rapid. Some of these have shown a significant amount of pitting edema within fifteen or twenty minutes of arising and would develop a tremendous amount of swelling if they were permitted to be up and about for an extended period. In spite of this rate and amount of edema these patients reduce the swelling quickly and easily on bed rest. It seems that under these circumstances the most likely explanation of rapid ebb and flow of the swelling is that there existed an open valveless channel such as described by Linton. When such patients are

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subjected to femoral vein ligation and concomitant saphenous vein excision, any degree of improvement has been questionable. Recently evidence has been presented based on venous pressure readings that ligation of the superficial femoral vein in postphlebitic states is of doubtful value. 23 REFERENCES 1. Leriche, R., Fontaine, R. and Dupertuis, S. M.: Arterectomy with Follow-up Studies on 78 Operations. Surg., Gynec. & Obst. 64: 149-155; 1937. 2. Kunlin, J.: Venous Grafts in Therapy of Endarteritis Obliterans. Arch. d mal du Coer. 42: 371-372,1949. 3. Fontaine, R., Buck, P., Riveaux, R., Kim, M. and Hubinont, J.: Sur Ie traitment des obliterations arterielles. De Ie valeur respective des thrombectomies et thrombocndarteriectomies, des shunts arterio-veineux, et des greffes vasculaires-autogreffes veineuses fraiches. Lyon chir. 46: 73. 1951. 4. Santos, (Dos) J.: Cid. Congres International de Chirurgie de Londres, 1947. Mem. Acad. de chir., June 4,1947; Pre sse med., June 15, 1949, p. 544. 5. Reboul, H. et Huguier, J.: Endarteriectomie aortico-iliaque gauche datant de seize mois. Mem. Acad. de chir. 75: 318,1949. 6. Bazy, L.: A propos du proces-verbal sur l'endarteriectomie desobliterante. Mem. Acad. de chir. 74: 109, 1948. Ibid, p. 104. 7. Bazy, L.: L'endart6riectomie pour arterite obliterante des membres inferieurs. J. internat. chir. 9: 95, 1949. 8. Bazy, L., Huguier, J., Reboul, H. and Laubry, P.: Technique des endarteriec· tomies pour arterite obliterante chronique des membres inferieurs, des iliaques et de l'aorte abdominale inferieure. J. de chir. 65: 196, 1949. Sur l'endarteriectomied esoblit6rante. Mem. Acad. de Chir., 1948, p. 109. 9. Bazy, L., Huguier, J., Reboul, H. and Laubry, P.: Desobliteration d'une thrombose ancienne segmentaire de 17 centimetres de long dans une art ere femorale superficielle atteinte d'arterite parietale calcifiee. Mem. Acad. de chir. 73: 602,1947. 10. Leriche, R.: Quatorze essais de thrombectomie arterielle suivant la methode de Jean Cid Dos Santos. Thrombo-endarteriectomie desobstruante. Mem. Acad. de chir., 1948, p. 101. (Discussion: MM. Louis Bazy et Ameline, p. 104-107. 11. Leriche, R.: Rapport sur la desobstruction des thromboses art6rielles anciennes. Mem Acad. de chir. 73: 409, 1947. 14 essais de thrombectomie art6rielle suivant la methode de Jean Cid Dos Santos. Thrombo-endarteriectomie arterielle desobstruante. Mem. Acad. de chir. 74: 100, 1948. Progres dans la Chirurgie Vasculaire. Congres de Londres, 1947. Lyon chir. 43: 149,1948. Mem. Acad. de chir., 1948, p. 101. 12. Leriche, R. and Kunlin, J.: Essais de des obstruction des arteres thromboses suivant la technique de J. Cid Dos Santos. Lyon chir. 42: 675 (Nov.-Dec.) 1947. 13. Kunlin, J.: Resultats de l'endarteriectomie experimentale. Etude histologique. M-m. Acad. de chir., 1948, p. 557. (Disc. M. Louis Bazy, p. 558.) Developpement anevrysmatique apres thromboart6riectomie de J. Cid Dos Santos. Mem. Acad. chir. 1948, p. 553. . 14. Freeman, N. Eo: Paper read before the Society for Vascular Surgery, June, 1951. 15. Loewe, L., Hirsch, Eo and Grayzel, D. M.: The Action of Heparin on Experimental venous Thrombosis. Surg. 22: 746, 1947. 16. de Takats, Geza and Evoy, Matthew H.: Lymphedema. Angiology 1: 73-79, 1950. 17. Ochsner, A. and DeBakey, M.: Post phlebitic sequelae. J.A.M.A. 139: 423, 1949.

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18. Ochsner, A., DeBakey, M., DeCamp, P. T., Richman, I. M., Ray, C. J., Llewellyn, R. C. and Creech, 0.: Postphlebitic Syndrome. Surgery 27: 161-182, 1950. 19. Linton, R. R. and Hardy, C. D., Jr.: Post-thrombotic Sequelae of the Lower Extremity. Treatment by Superficial Femoral Vein Interruption and Stripping of the Saphenous Vein. S. CLIN. NORTH AMERICA. 27: 1171, 1947.

20. Idem: Post-thrombotic Syndrome of Lower Extremity. Treatment by Interruption of the Superficial Femoral Vein and Ligation and Stripping of Long and Short Saphenous Veins. Surgery 24: 452, 1948. 21. Bauer, G.: The Etiology of Leg Ulcers and Their Treatment by Resection of the Popliteal Vein. J. internat. chir. 8: 937, 1948. 22. de Takats, Geza, and 'Graupner, G. W.: Division of the Popliteal Vein in Deep Venous Insufficiency of the Lower Extremities. Surgery 29: 342, 1951. 23. DeCamp, P. T., Schramel, R. J., Ray, C. J., Feibleman, N. D., Ward, J. A.

and Ochsner, A.: Ambulatory Venous Pressure Determinations in Postphlebitis and Related Syndromes. Surgery 29: 44, 1951.