The Lower-Extremity Allen Test

Pyridinolcarbamate; Anginin (B23) is a venous bradykinin antagonist, which antagonizes competitively and reversibly the venoconstrictive effect of bradykinin and its active homologues. This compound has also been shown to antagonize the congestion, exudation and hemorrhage induced by brady-kinin and its active homologues and to remove the edematous change from experimental atheroma and to promote the normal fibrous healing of atheroma.This compound has also exhibited clinically a beneficial effect in the atherosclerotic diseases of the brain and the heart, however, the evaluation of the effectiveness of this kind of drug in these morbid conditions had to depend upon rather the indirect evidences. In order to see directly the effect of pyridinolcarbamate on the arterial lesion the atherosclerosis of extremities seems much more suitable. The authors have first attempted this compound in the treatment of atherosclerotic occlusion in lower extremities of 2 hos-pitalized patients; 33 years old and 57 years old men.The first patient aged 33 years suffered from a marked cyanosis of his right foot with a history of 6 months and the pulsations of right popliteal, posterior tibial and dorsal pedal arteries were completely absent and arterio-graphy revealed the complete obstruction of popliteal artery immediately above the knee joint. Pyridinolcarbamate was given 1Gm. daily and on the 3rd day of the medication the cyanosis disappeared dramatically and the intermittent claudication exhibited a slight improvement. On the 14th day of the medication the right dorsal pedal pulsation was recognized and on the 15th day the pulsation became visible through the skin and at the same time the pulsation of right popliteal artery began to be recognized. The volume of pulsation increased gradually but relatively rapidly and concomi-tantly with the remarkable improvement of intermittent claudication and on the 25th day of the treatment there was no differnce of skin temperature be-tween right and left foot and the pulsation exhibited almost normal volume in dorsal pedal artery. On the 26th day the pulsation of his right posterior tibial artery also reappeared. Under the medication of this compound no relapse and no untoward effects of the drug have been noted for 3 months period of the observation.The second case aged 57 years suffered from intermittent claudication and the absence of the pulsation of bilateral popliteal, dorsal pedal and pos-terior tibial arteries and the arteriography revealed the occlusion of the middle part of the right femoral artery.The treatment with pyridinolcarbamate for 2 weeks in a daily dose of one Gm. induced a slight improvement of intermittent claudication and on the end of third week a marked improvement was noted and at the same time the pulsation of his right dorsal pedal artery reappeared. His inter-mittent claudication exhibited a marked improvement concomitantly with the appearance of his dorsal pedal artery. A definite shortening in crest time in plethysmogram was noted in the bilateral second toes on the 130th day of the treatment. Thereafter his condition has been continuously good and he had no relapse and no untoward effects of the drug during the whole observation period of 5 months.The effect of pyridinolcarbamate seems to originate from the improve-ment of atheromatous changes by the compound in these patients.

BackgroundInvestigating basal blood perfusion in the major arteries of the limbs to guide flow rate selection during ex vivo perfusion preservation for limb replantation (transplantation).MethodsVolunteers undergoing physical examinations at PLAGH Fourth Medical Center (February–December 2024) were recruited. Three hundred and four eligible participants (146 males, 158 females; aged 18–65, mean 41.68 ± 11.28) were enrolled after screening. A portable Doppler ultrasound system was utilized to assess the brachial, ulnar, radial, popliteal, dorsalis pedis, and posterior tibial arteries in the limbs. Vascular diameter, blood flow velocity, and blood perfusion volume were measured for each artery. Mean hemodynamic parameters were calculated. Analyze the linear relationship between BMI, body surface area, and arterial blood perfusion volume using a multiple linear regression model. Conduct interaction tests to investigate whether there are sex-specific or “three-high” status-specific effects in the linear prediction model of blood perfusion volume by BMI and body surface area.ResultsUltrasound findings revealed the following mean blood perfusion volumes in the upper limb arteries: brachial artery, 74.9 ± 22.5 mL/min; ulnar artery, 35.7 ± 12.6 mL/min; radial artery, 36.8 ± 13.5 mL/min. In the lower limb arteries, the mean blood perfusion volume was: popliteal artery, 114.1 ± 34.2 mL/min; dorsalis pedis artery, 53.3 ± 18.1 mL/min; posterior tibial artery, 59.2 ± 21.0 mL/min. No significant difference was observed in mean blood perfusion volume between the ulnar and radial arteries (p > 0.05), whereas the posterior tibial artery exhibited significantly higher blood perfusion volume compared to the dorsalis pedis artery (p < 0.001). Multiple linear regression analysis revealed that BMI was negatively associated with arterial blood perfusion volume in the extremities, while body surface area showed a positive association. Furthermore, BMI and body surface area jointly formed a linear predictive relationship with limb blood flow. Based on significant effects within the linear model and pathophysiological mechanisms, interaction terms for body surface area (BSA) × BMI and age × diabetes status were included. The results demonstrated a statistically significant interaction effect (p < 0.05) between BMI and body surface area on limb blood flow. However, the interaction effect of diabetes status on limb blood flow was not significant (p > 0.05).ConclusionQuantitative ultrasound-derived limb perfusion parameters and their BMI/BSA correlations enable hemodynamic customization for machine perfusion systems in limb replantation. This standard approach balances metabolic support and ischemia-reperfusion risk mitigation during extracorporeal preservation, advancing personalized transplant protocols.

Objective To analyse the risk factor of vascular crisis following free compound tissue transplantation in order to avoid the risk factor and improve the survival rate of free compound tissue. Methods Sixteen patients with free compound tissue transplantation were retrospectively reviewed between June, 2010 and December, 2015. The age, sex, injury reason, operation time, injury site and donor vessel of the patients were recorded and analysed.The risk factors of free transplanted compound tissue necrosis were concluded. Results Of 16 cases, 5 cases were anterolateral thigh flap, 4 cases medial peroneal artery flap, 2 cases osteocutaneous flap, 1 case toe transplantation, 1 case medial plantar artery flap, 1 case forearm reverse interosseous posterior artery flap and 1 case groin flap. In 16 patients with free compound tissue transplantation, there was no difference in sex and age (P>0.05) . The percentage was higher in the patients injured by vehicle than the patients injured by non-vehicle (P<0.05) . The percentage was lower in the patients with operation within 4 weeks after wound than beyond 4 weeks (P<0.05) .Transplanted tissue necrosis was prone to appear in the patients with low limb injury. The incidence of transplanted tissue necrosis was higher in low limb than in upper limb, and the highest in foot (P<0.05) . If the donor vessel was the dorsalis pedis artery, anterior tibial artery or posterior tibial artery, the incidence of transplanted tissue necrosis was very high. The highest rate was the dorsalis pedis artery (P<0.05) . Conclusion Injury by vehicle, surgery happening beyond 4 weeks after wound and injury in low limb were the high risk factor of tissue necrosis following free compound tissue transplantation. Key words: Surgical flap; Vascular crisis; Necrosis; Risk factor; Retrospectively analusis

Introduction: In patients with diabetic foot ulcers, atherosclerosis, and endothelial dysfunction can worsen the patient’s vascular condition. Atherosclerosis is one of which is assessed by the ankle-brachial index (ABI). The occurrence of endothelial dysfunction can be identified indirectly from the examination of flow-mediated dilatation (FMD) via doppler ultrasound. This study was conducted to determine whether there is a correlation between the ankle-brachial index examination with ultrasound examinations of the dorsalis pedis artery and posterior tibial arteries in diabetic foot sufferers. Method: The study design was a cross-sectional prospective conducted on 11th November – 15th December 2014 at Cipto Mangungkusumo National Hospital, Fatmawati National Hospital, and Tangerang Hospital. The inclusion criteria used were diabetics and allow for ABI examination and ultrasonography. Patients who did not have a precise diagnosis and had undergone a major amputation of the leg examined were excluded from the study. Results: From the Spearman non-parametric correlation analysis test results obtained significant results on the correlation between ABI and posterior tibial artery volume flow (VF) (p=0.021). In contrast, insignificant results were obtained on the correlation between peak systolic velocity (PSV) dorsalis pedis artery with ABI (p=0.561), as well as an insignificant correlation between VF of dorsalis pedis artery with ABI (p=0.143), as well as insignificant correlation on PSV of posterior tibial artery with ABI (p=0.231) The results of Spearman’s non-parametric correlation analysis test results obtained significant results on the correlation between ABI and ABI spectral picture (p=0,000) in the diabetic foot. Conclusion: There was a significant correlation between the posterior tibial artery VF with ABI and the Doppler ultrasound spectral picture with ABI. Keywords: ultrasound doppler, ankle-brachial index, diabetic foot ulcer, dorsalis pedis artery, popliteal artery

Dorsal pedis perforator flap is a flap with blood supply from dorsal pedal artery or dorsal metatarsal artery, and can be designed as the perforator flap pedicled with dorsal pedal artery or with dorsal metatarsal artery. The flap has sensory nerves and is characterized by small thickness, long vascular pedicle, and a wide diameter of the blood vessel which is convenient for anastomosis. As one of the commonly used flaps in clinical practice, it is a great convenience to use dorsal pedis perforator flap for pedicled flap transplantation or free flap transplantation. However, a poor coverage on the donor site may compromise the functions of the foot and shoes wearing, so it should be cautiously selected.

We report on 4 patients with the campomelic syndrome (CS) in whom postmortem angiography of the lower limbs was performed. Of the 4 patients, 3 were phenotypic females (2 of them with a 46,XY karyotype) and one was a male with a normal 46,XY karyotype. Three fulfilled the criteria of CS, and one (phenotypically female with a 46,XY karyotype) lacked the lower limb bowing and the talipes equinovarus typical of CS. This infant may constitute a further example of the recently reported CS without campomelia. The results of the angiographic study are compared with 46 postmortem angiographies of normal fetuses and newborn infants at different gestational ages. In the first 3 CS patients the main arterial axis of the lower limb, formed by the superficial femoral and anterior tibial arteries, had smaller diameters than expected while the profunda femoris and posterior tibial arteries had greater diameters than age-matched controls. However, the most striking abnormality was the absence or marked deficiency of the anterior tibial artery. Its terminal branch, the dorsalis pedis artery, was also absent and the plantar arch was abnormally formed by the posterior tibial artery either alone or in conjunction with the peroneal artery. The normal arterial pattern was found in the patient who lacked bowed bones. This finding supports a developmental association between vascular defects and lower limb anomalies in CS. This aberrant arterial pattern in CS may affect or be affected by muscle development. The shortness of the posterior femoral and calf muscles fix the knee and the ankle joints.(ABSTRACT TRUNCATED AT 250 WORDS)

Translated article] Graphic representation of intraosseous and extraosseous talus blood supply. Illustrated anatomy

We evaluated the posterior tibial artery as an alternative arterial cannulation site to the radial artery in small children. A two-stage study was conducted. First, we evaluated the anatomical characteristics of the posterior tibial artery compared with the radial and dorsalis pedis arteries. Next, a parallel-arm single-blind randomized controlled study compared the initial success rate of ultrasound-guided arterial cannulation among three arteries as a primary outcome. Sixty patients were analyzed in the observational study. The diameter of the posterior tibial artery (1.5 ± 0.2 mm) was similar to that of the radial artery (1.5 ± 0.2 mm) and larger than that of the dorsalis pedis artery (1.2 ± 0.2 mm; P < 0.001). The posterior tibial artery has a larger cross-sectional area (2.8 ± 1.1 mm) compared with the radial (2.3 ± 0.8 mm; P = 0.013) and dorsalis pedis arteries (1.9 ± 0.6 mm; P = 0.001). In total, 234 patients were analyzed in the randomized study. The first-attempt success rate of the posterior tibial artery (75%) was similar to that of the radial (83%; P = 0.129; odds ratio, 1.53; 95% CI, 0.69 to 3.37) and higher than that of the dorsalis pedis artery (45%; P < 0.001; odds ratio, 3.95; 95% CI, 1.99 to 7.87). Median cannulation time of the posterior tibial artery (21 s; interquartile range, 14 to 30) was similar to that of the radial artery (27 s; interquartile range, 17 to 37) and shorter than that of the dorsalis pedis artery (34 s; interquartile range, 21 to 50). The posterior tibial artery is a reasonable alternative to the radial artery for ultrasound-guided arterial cannulation in small children.

The Achilles tendon is the most frequently ruptured tendon in the lower limb and accounts for almost 20% of all large tendon injuries. Despite numerous published studies describing its blood supply, there has been no uniformity in describing its topography. The current study comprises a detailed anatomical study of both the intrinsic and extrinsic arterial supply of the Achilles tendon, providing the detail sought from studies calling for improved planning of surgical procedures where damage to the vascularity of the Achilles tendon is likely. A dissection, microdissection, histological, and angiographic study was undertaken on 20 cadaveric lower limbs from 16 fresh and four embalmed cadavers. The Achilles tendon is supplied by two arteries, the posterior tibial and peroneal arteries. Three vascular territories were identified, with the midsection supplied by the peroneal artery, and the proximal and distal sections supplied by the posterior tibial artery. The midsection of the Achilles tendon was markedly more hypovascular that the rest of the tendon. The Achilles tendon is at highest risk of rupture and surgical complications at its midsection. Individuals with particularly poor supply of the midsection may be at increased risk of tendon rupture, and approaches to the tendon operatively should consider the route of supply by the peroneal artery to this susceptible part of the tendon.

Objectives The main factor in the healing of foot ulcers in diabetic patients is adequate perfusion. There is no consensus on whether direct or indirect revascularization is more effective in leg revascularization. At the centre of that debate, there is a disagreement about whether collateral circulation is sufficient or not. Our aim is to evaluate collateral circulation activity between angiosomes in the feet of diabetic patients by evaluating the level of occlusion in leg arteries and comparing the angiosome regions that have necrosis. Methods The study included 61 patients. All had undergone CT angiography to the lower extremity prior to any revascularization of the leg arteries between September 2014 and September 2016. Stenosis was evaluated on the anterior tibial artery, the posterior tibial artery and the peroneal artery up to the level of the ankle. The opening of the vessel wall at the narrowest part of the vessel was determined as a percentage. The areas with necrosis were determined according to the angiosomes of the posterior tibial artery, anterior tibial artery and peroneal artery vessels. Results Necrosis of the foot was most common in the posterior tibial artery angiosome. Necrosis in the posterior tibial artery angiosome was independent of the level of posterior tibial artery occlusion; however, it was associated with the occlusion of the anterior tibial artery ( p < 0.05). It was found that anterior tibial artery occlusion over 15% resulted in necrosis in the posterior tibial artery angiosome. Conclusions Collateral circulation between the anterior tibial artery and posterior tibial artery is active and there is almost always occlusion in the posterior tibial artery branches. The posterior tibial artery angiosome is fed by the collateral arteries of the anterior tibial artery even if there is no occlusion of posterior tibial artery at the level of the leg, so indirect revascularization on the anterior tibial artery is sufficient to provide foot circulation.

Objective: In order to increase the survival rate of clinical thumb reconstruction, the Doppler ultrasound (DU) imaging technology based on the minimum variance adaptive beamforming (MV) algorithm is applied to the preoperative examination of thumb reconstruction. Method: 75 patients who needed thumb reconstruction were divided into 40 study group and 35 traditional group. Before operation, color Doppler ultrasound was used to examine saphenous vein, radial artery in the receiving area, dorsalis pedis artery and cephalic vein in the donor area to determine whether there was abnormality. In addition, the branch type of toe web and the Gilbert type of the first dorsal metatarsal artery were examined and confirmed. Through ultrasound examination, the operation plan was determined. In the traditional group, through doctor's pen Doppler auscultation or touch feeling, the great saphenous vein-dorsalis pedis vein-dorsal metatarsal veins-dorsal digital veins of foot was dissected in the traditional way without ultrasonic examination. The MV algorithm was used to process the ultrasonic image. Results: The ultrasonic image processed by MV algorithm is clearer and higher quality. There is no absence of dorsalis pedis artery in the contralateral donor area in 75 patients. There is no vascular crisis in the study group and one patient in the traditional group. The average operation time in the Gilbert III study group is 90 minutes, compared with 135 minutes in the traditional group. There is no walking pain of donor foot in the study group after Gilbert III operation, and there are three walking pain in the traditional group. Conclusion: The MV algorithm can be used in thumb reconstruction. It can detect the branch type of toe web and the Gilbert type of the first dorsal metatarsal artery. On this basis, the operation plan can be determined, which can reduce the blindness of the operation, shorten the operation time, increase the survival rate of the reconstructed thumb, and reduce the incidence of complications of the donor foot.

Best reproducibility of the ankle–arm index was calculated using Doppler and dividing highest ankle pressure by highest arm pressure

Tomographic Ultrasound Angiography for Peripheral Artery Disease

Research Type:Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studiesIntroduction/Purpose:The risk of vascular injury is a significant concern in posterior malleolus surgery, especially with the commonly used posterolateral approach. Anatomical variations of the peroneal artery, such as the presence of a communicating branch to the posterior tibial artery, may heighten this risk. This study investigates the prevalence of this communicating branch and its implications for surgical decision-making, advocating for the medial-posteromedial approach as a safer alternative.Methods:To identify the presence of a communicating branch between the peroneal and posterior tibial arteries, a retrospective analysis of 916 lower limb computed tomography angiographies (CTA) was performed. Patient data were stratified based on clinical indication for imaging, laterality, and the presence or absence of the communicating branch.Results:A communicating branch was identified in 289 (31.6%) of the cases. The prevalence was significantly higher in patients with PVD (n = 227) compared to those imaged for trauma (n = 18), free fibula graft assessment (n = 16), or other vascular concerns (n = 28). Notably, in cases where the communicating artery was present, 40% had an atretic proximal posterior tibial artery, making the peroneal artery, with its communicating branch, the primary blood supply to the medial plantar arch of the foot. This anatomical variation poses a substantial risk of arterial compromise if the posterolateral approach is used, as it necessitates ligation of these branches.Conclusion:Our findings reinforce the existing anatomical literature regarding the variability of peroneal artery branching and underscore the potential hazards of a posterolateral approach to the posterior malleolus. Inadvertent ligation of the communicating branch may lead to ischemic complications, such as flexor hallucis longus contracture. Given the high prevalence of this variation, particularly in patients with PVD, the posterolateral approach should be approached with caution. The medial-posteromedial approach provides a safer alternative, preserving vascular integrity while ensuring more than adequate surgical exposure for posterior malleolus fracture fixation.

Delayed Presentation of a Posttraumatic Superficial Femoral Artery Pseudoaneurysm