American journal of surgery
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Randomized Controlled Trial Comparative Study Clinical Trial
Results of a prospective, randomized trial of surgery versus thrombolysis for occluded lower extremity bypass grafts.
The purpose of this study was to prospectively evaluate the treatment of patients with occluded lower extremity bypass grafts, comparing surgical revascularization with catheter-directed thrombolysis. ⋯ Proper catheter positioning currently limits the potential of catheter-directed thrombolysis for lower extremity bypass graft occlusion. Patients with graft occlusion > 14 days have a significantly better outcome when treated surgically, with a new bypass being the best surgical option. However, in patients with acute limb ischemia (< 14 days) successful thrombolysis of occluded lower extremity bypass grafts improves limb salvage and reduces the magnitude of the planned surgical procedure. Patients with occluded prosthetic grafts suffer more major morbid events compared with occluded autogenous grafts.
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Deep vein thrombosis (DVT) has been reported to occur in 20% to 40% of high-risk trauma patients if no prophylaxis is used. The purpose of this study was to determine the incidence of DVT and utility of a screening program in a high-risk group of trauma patients for whom routine DVT prophylaxis was utilized. ⋯ These results suggest that standard use of DVT prophylaxis in a high-risk trauma population leads to a low incidence of DVT and that a screening protocol is effective in detecting unsuspected DVTs. Use of a surveillance protocol, however, may reduce but will not eliminate the incidence of pulmonary emboli in this patient population.
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Although foot compression increases foot skin perfusion and calf compression increases popliteal artery blood flow, these compression techniques have not been evaluated in combination. The purpose of this study was to evaluate whether calf and foot compression applied separately and simultaneously increase popliteal artery blood flow and/or foot skin perfusion, and to assess the relative merits of compression in patients with superficial femoral artery occlusion. ⋯ Measured in the sitting position, the resting popliteal artery blood flow and foot skin perfusion are greater in patients with SFA occlusion compared with normal volunteers. Following compression, popliteal artery blood flow and foot skin perfusion increased in both groups, but relatively more in volunteers. Increases in popliteal artery blood flow are significantly higher with calf compression than with foot compression for both groups. A patent SFA allows for additive increases in popliteal artery blood flow with simultaneous foot and calf compression in normal persons, whereas this is not observed in patients. However, the increases in foot skin perfusion in patients with an occluded SFA parallel the increases shown in normal volunteers, with separate and simultaneous foot and calf compression.
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The traditional approach to decompression of the thoracic outlet has been by transaxillary resection of the first rib. Recently, the trend has been toward a more selective and tailored surgical approach via the supraclavicular route. ⋯ A selective approach to thoracic outlet decompression, consisting of anterior scalenectomy and brachial plexus neurolysis for neurogenic symptoms, and reserving first rib resection for arterial and venous indications, is a safe procedure and yields satisfactory results in appropriately selected patients.