European journal of vascular surgery
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Comparative Study
Non-invasive Doppler-derived cardiac output: a validation study comparing this technique with thermodilution and Fick methods.
The high mortality and morbidity related to cardiac events remains a considerable problem in vascular surgery. Predicting high risk patients is difficult except perhaps by coronary angiography which is invasive, costly and impractical. It would be useful to have a technique which could easily measure cardiac output and stratify cardiac risk in patients needing vascular surgery. ⋯ Bland and Altman's statistical method showed the differences to be normally distributed. The mean difference (thermodilution minus Doppler) was 0.32 l/min SD 0.48 l/min, 95% confidence limits -0.64 to +1.28 l/min. Doppler-derived cardiac output compares well with traditional methods of measurement and may be a useful tool in the assessment and monitoring of the high risk vascular patient.
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Equilibrium radionuclide angiocardiography (ERNA) was employed preoperatively in 183 patients undergoing elective abdominal aortic reconstruction to measure left ventricular ejection fraction (LVEF) and to detect abnormal regional wall movement. Abnormal ejection fractions were virtually confined to the 97 patients who had clinical, electrocardiographic or radiographic evidence of heart disease. An operative mortality of 8.7% was recorded. ⋯ Patients with an abdominal aortic aneurysm and abnormal LVEF or regional wall motion abnormality were more likely to suffer a cardiac event (p less than 0.001), the event rate exceeding 60% in patients whose LVEF was less than 35%. An abnormal LVEF failed to predict a cardiac event in patients with aorto-iliac occlusive disease. While not indicated in patients lacking clinical evidence of heart disease, ERNA can refine the assessment of cardiac risk, particularly in patients with previous myocardial infarction and define a high risk group in whom aortic reconstruction should be avoided except for the most compelling of indications.
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Randomized Controlled Trial Comparative Study Clinical Trial
The role of central haemodynamic monitoring in abdominal aortic surgery. A prospective randomised study.
To test the hypothesis that central haemodynamic monitoring is not necessary in all patients undergoing abdominal aortic surgery, a prospective randomised study in 40 consecutive patients undergoing elective abdominal aortic surgery was carried out. Patients with unstable angina, recent myocardial infarction (less than or equal to 6 months), and left ventricular ejection fraction (LVEF) less than 0.50 were excluded. Twenty-one patients had perioperative central haemodynamic monitoring while 19 patients had central venous pressure monitoring alone. ⋯ Statistical analysis failed to show any difference in outcome for any variable measured in either low risk group. All serious postoperative cardiac complications occurred in patients with LVEF less than 0.50 (P less than 0.0001). These data suggest that patients with LVEF greater than or equal to 0.50 are at low risk of developing postoperative cardiac complications and can be successfully managed perioperatively without the added potential risks and costs of central haemodynamic monitoring.
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A total of 119 patients with acute peripheral arterial ischaemia were studied prospectively to validate the definition of acute critical ischaemia suggested by the working party of the International Vascular Symposium. The majority of the patients had primary treatment using thrombolytic therapy. ⋯ Comparisons of the outcome in patients with or without a distal neurosensory deficit (limb salvage 30% vs. 72%, P = 0.0001) and those with absent or audible Doppler ankle blood flow (limb salvage 37% vs. 78%, P = 0.0001) confirmed that the severity of the initial ischaemia was a significant indicator of prognosis. The definition of acute critical ischaemia as assessed by objective measurement of Doppler pressures has been validated and can be used to divide patients into groups with critical and sub-critical ischaemia with different prognoses.