Parks 915-BL Operating & Service Manual page 31

The angiogram, however, does not yield
information regarding the hemodynamic
significance of the lesion. For this information
the Doppler flow detector is a useful and
accurate instrument. The importance of the
ankle/arm systolic blood pressure ratio in the
diagnosis and objective assessment of arterial
disease underscores the value of the Doppler
ultrasound blood flow detector. Although the
auscultatory method with a stethoscope is
one of the most common blood pressure
measurements in clinical medicine, it is seldom
used in the lower exremity because it is
difficult to obtain the Korotkoff sounds in
the distal portion of a limb, especially when
arterial occlusive disease is present. The
Doppler flow detector, when used with a
sphygmomanometer and a pneumatic occlusion
cuff, can measure the lower extremity systolic
blood pressure easily and accurately.
Normally, the ankle systolic blood pressure is
slightly higher than the arm systolic blood
pressure. Any pressure gradient or difference
that exists between the arm and ankle systolic
blood pressure provides a valuable, objective
hemodynamic assessment of the arterial lesion.
Certainly, the lower the ankle systolic blood
pressure when compared to that in the arm,
the greater the gradient and therefore, the more
advanced the arterial occlusive lesion in the
distal abdominal aorta or lower extremity
arteries.
Two of the most important aspects of
managing patients with Arteriosclerosis
obliterans are the need to avoid any form of
injury to the affected foot; this includes the
avoidance of any form of home surgery on the
feet, and the avoidance of tobacco smoking. A
recent study of ours indicates that 40 percent
of major lower extremity amputations might
have been avoided by taking simple
precautions against infections stemming
from mechanical, thermal, or chemical
injuries to the feet. Meticulous, periodic
podiatric care is necessary for any foot with
an impaired circulation with its known
increased susceptibility to infection. Even
fungal infections such as athlete's foot can put
the ischernic foot at serious risk. Certain
over-the-counter pharmaceutical preparations
for removing corns and calluses that contain
c a u s t i c c h e m i c a l s c a n b e h a r m f u l t o
surrounding tissues, especially when used in
the presence of an impaired circulation and
should be avoided!
Thromboendarterectomy of the occluded
artery or the use of bypass grafts are the
operative procedures most frequently used for
revasculatization of the ischernic limb.
Sympathectomy may be helpful in certain
patients, but is is rarely considered for patients
who are candidates for arterial surgery and it is
not recommended for treatment of intermittent
claudication. However, minor ischemic
ulcerations may heal and rest pain may
occasionally be relieved
sympathectomy.
A limited number of patients with advanced
arteriosclerosis obliterans may show
improvement over periods of weeks from
nonsurgical measures including rest, the use of
vasodilators, and avoidance of tobacco smoking,
permitting the development of an additional
collateral circulation. However, the long period
before results can be evaluated is risky:
gangrene may supervene, calling for emergency
surgical reconstruction of the occluded
vascular bed if amputation is to be avoided.
CONCLUSION
There are both humanitarian, economic and
social reasons for mounting a strong effort to
salvage the lower limbs in patients, who are
often elderly, and debilitated, but obvious
candidates for a revascularization procedure.
The physical, psychological and economic
burdens following amputation preclude a useful
or comfortable life in the years remaining to
them.
Limb salvage, the desideraturn of any age, is
particularly important in the geriatric patient
whose care then places a heavy burden on a
spouse of similar age or another family member.
A patient confined to a wheelchair or bed is
unable to attend to even the simplest personal
needs; he often becomes withdrawn from
human contacts, psychologically as well as
physically damaged.
Partial limb revascularization, by saving the
extremely valuable knee joint, is often a
reasonable alternative, allowing salvage of as
much as possible of a limb affected by end-stage
ischernia.
The goal should be treatment of the disease
without loss of the lower limb or, if amputation
becomes necessary, a below-knee procedure or
even a transmetatarsal amputation, permitting
the patient to lead a more normal life.
222 East 19th Street
New York, New York 10003
*Attending Vascular Surgeon, Cabrini Medical Center, New
York, N.Y.; Associate Professor of Surgery, New York,
University School of Medicine, New York, N.Y.
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