Outcomes from a proof-of-concept specialist lymphoedema clinic in the community

The Health and Safety Execultive lymphoedema model of care was published in 2018 highlighting the lack of dedicated lymphoedema services in Ireland. This led to the introduction of a proof-of-concept primary care specialist lymphoedema clinic. The clinic was responsible for all patients from their county. A comprehensive dataset was gathered which included the patient's history for 1 year prior to their presentation at clinic and then 6 monthly. A quality of life tool (LymQoL) and a patient satisfaction survey were completed. Completed 1-year data showed a significant reduction in GP and public health nurse visits as well as a reduction in the occurrence of cellulitis and associated hospital admissions. All areas of quality of life were improved and patient satisfaction was either excellent (89%) or very good (11%). The 1-year findings strongly support the roll-out of specialist clinics to all regional health areas.

COVID-19, when fourteen days are not enough-A case series of affected healthcare workers

We highlight the need for planning for mass workforce absentees as we prepare for subsequent surges. We suggest a multicomponent intervention including guiding return dates more by symptomatology and fitness for work rather than infectivity status.

Relationship between 'on-treatment platelet reactivity', shear stress, and micro-embolic signals in asymptomatic and symptomatic carotid stenosis

BACKGROUND

Assessment of 'high on-treatment platelet reactivity (HTPR)' could enhance understanding of the pathophysiology of first or recurrent vascular events in carotid stenosis patients on antiplatelet therapy.

METHODS

This prospective, multi-centre study assessed antiplatelet-HTPR status and its relationship with micro-emboli signals (MES) in asymptomatic vs. symptomatic ≥ 50-99% carotid stenosis. Platelet function/reactivity was assessed under 'moderately high shear stress' with the PFA-100^® and 'low shear stress' with VerifyNow^® and Multiplate^® analysers. Bilateral 1-h transcranial Doppler ultrasound of the middle cerebral arteries classified patients as MES + ve or MES - ve.

RESULTS

Data from 34 asymptomatic patients were compared with 43 symptomatic patients in the 'early phase' (≤ 4 weeks) and 37 patients in the 'late phase' (≥ 3 months) after TIA/ischaemic stroke. Median daily aspirin doses were higher in early symptomatic (225 mg; P < 0.001), but not late symptomatic (75 mg; P = 0.62) vs. asymptomatic patients (75 mg). There was a lower prevalence of aspirin-HTPR in early (28.6%; P = 0.028), but not late symptomatic (38.9%; P = 0.22) compared with asymptomatic patients (56.7%) on the PFA-100^®, but not on the VerifyNow^® or Multiplate^® (P ≤ 0.53). Early symptomatic patients had a higher prevalence of aspirin-HTPR on the PFA-100^® (28.6%) vs. VerifyNow^® (9.5%; P = 0.049), but not Multiplate^® assays (11.9%, P = 0.10). There was no difference in aspirin-HTPR prevalence between any symptomatic vs. asymptomatic MES + ve or MES - ve subgroup.

DISCUSSION

Recently symptomatic moderate-severe carotid stenosis patients had a lower prevalence of aspirin-HTPR than their asymptomatic counterparts on the PFA-100^®, likely related to higher aspirin doses. The prevalence of antiplatelet-HTPR was positively influenced by higher shear stress levels, but not MES status.

Explant of aortic stent grafts following endovascular aneurysm repair

Background

Failure of endovascular aneurysm repair may require explant of the stent graft in a subset of patients. We sought to assess outcomes in a cohort of patients undergoing explant of endovascular aneurysm repair in both emergency and elective settings.

Methods

Patients undergoing explant of endovascular aneurysm repair were identified from a prospectively maintained database, with additional information obtained through retrospective analysis of medical records.

Results

Over a 21-year period, 1997–2018 (May), there were 597 endovascular aneurysm repair procedures performed in our institution for abdominal aortic aneurysm. There were 19 endovascular aneurysm repair explants; five of these were referrals from other vascular centres. The median age was 73 years (range 46–81). The median length of time from insertion to explant was 39.2 months (range 0–153). Indications for elective explant were type Ia endoleak (n = 4), type 1b endoleak (n = 1), type II endoleak with increasing sac size (n = 1), type I/III endoleak (n = 1), type IV endoleak (n = 1), and increasing sac size without evident endoleak (type V, n = 2). The remaining nine cases were emergency procedures, with four patients presenting with rupture post endovascular aneurysm repair, four patients presenting with acute stent thrombosis, of which one also had a type 1a endoleak and one aorto-enteric fistula. There were no mortalities in the elective group and three mortalities in the emergency group (0 vs 33.3%, p = 0.087). Overall 30-day mortality was 15.8%

Conclusion

Explant of aortic stent grafts can be associated with high mortality and morbidity rates, especially in the emergent setting. Patient and device selection and post-operative surveillance remain vitally important to optimise outcomes post endovascular aneurysm repair.

Emergency endovascular management of acute thoracic aortic pathology A safe and feasible option

Endovascular repair has revolutionised the emergency treatment of thoracic aortic disease. We report our 10 year experience using this treatment in emergency cases. A prospectively maintained vascular database was analysed. Patients' medical records and CT images stored on the hospital PACS system were also reviewed. Statistical analysis was done using IBM SPSS V21. There were a total of 59 thoracic aortic stenting procedures of which 33 (60% males with a mean age of 58 yrs) were performed for emergency thoracic pathologies: traumatic transection (n = 10), ruptured aneurysm (n = 6), non-traumatic dissection (n = 8) and penetrating aortic ulcer (n = 9). All patients had self-expanding endografts implanted. Two patients required debranching procedures before the endovascular treatment. Thirty-day mortality was 12.1% (4/33). 70% of patients received a single device. There were 7 procedure related complications, 6 requiring re-intervention: thoracotomy and drainage in 2 patients, proximal graft extension in 2, open drainage of groin haematoma in 1 and open repair of a common femoral artery pseudo-aneurysm in one patient. In total 23 patients were transferred from 11 centres nationwide. There were no mortalities or other complications related to patient transfer from peripheral centres. Although acute thoracic aortic pathology is life threatening, appropriate blood pressure management and treatment of associated injuries can result in favourable outcomes. Endovascular repair is a safe and effective treatment option which enables patients to be treated with reduced morbidity and mortality. Transfer of patients with acute pathology to a tertiary centre can safely be performed.

The accuracy of anatomical landmarks for locating the carotid sinus

BACKGROUND

carotid sinus massage (CSM) is a valuable clinical test for carotid sinus syndrome (CSS) and relies on accurately locating the carotid sinus (CS).

OBJECTIVE

in this study, we sought to examine the accuracy of using anatomical landmarks for locating the CS.

METHODS

consecutive patients (n = 20) were recruited prospectively. Two clinicians, trained in CSM, were asked to locate the CS using anatomical landmarks. A point on the skin overlying the CS was then marked by a vascular technician using ultrasound. Accuracy of techniques was compared using intra-class correlation coefficients and Bland-Altman statistics.

RESULTS

anatomical landmarks underestimated the CS location by 1.5 ± 1.3 cm. Error extremes ranged from 4 cm below to 2 cm above CS using anatomical landmarks. A moderate correlation between ultrasound and anatomical landmarks was found, r = 0.371 (P = 0.031).

CONCLUSION

this is the first study to characterise the accuracy of standard anatomical landmarks used in CSM. Results suggest that the point of maximal pulsation has the lowest associated error. Future work should examine CSM yield across this and a range of other methodological factors.

Results of an Infection Control Survey in Ultrasound Departments and Recommended Guidelines

Prevention of disease transmission by cross infection is very important in the hospital environment to protect both staff and patients.

At the present time most hospitals have stringent infection control policies which are largely geared toward the wards, critical care units and the operating theatres but there does not appear to be specific guidelines for ultrasound departments. Considering the contact nature of the ultrasound examination and the large number of tests that are performed in most hospitals annually it was felt that this was an area that needed to be addressed. One must be aware not only of protection of patients and staff but also of care in the cleaning of expensive equipment.

We undertook a national survey of the larger general ultrasound departments, vascular and cardiac laboratories to establish current practices and to assess whether these are adequate. We also contacted a number of ultrasound companies and requested cleaning specifications for their equipment.

The full results of the survey, the biological effectiveness of different cleaning techniques and their compatibility with ultrasound transducers will be discussed. Finally, recommendations regarding safe effective cleaning procedures and sensible infection control precautions in ultrasound departments will be made.

Low Dose Intraarterial Thrombolysis with Tissue Plasminogen Activator: Does It Deliver as Promised?

The widespread use of intraarterial thrombolytic therapy has been based on perceived benefits over operative treatment and the downgrading of the magnitude of subsequent surgery. Thirty-three patients who had thrombolysis for peripheral artery occlusion were retrospectively analyzed at St. James's Hospital from 1991 to 1997. One patient received streptokinase unsuccessfully. Five other patient's records were inadequate for analysis. Twenty-seven patient's notes were analyzed for risk, duration of occlusion, duration of treatment, dosage of tissue plasminogen activator (tPA) and conduits thrombolysed. There were 15 males and 12 females. The mean age was 62 years (range, 20-87). Fourteen were current or reformed smokers. Five were diabetic. Indications for treatment included acute graft occlusion (n = 13), embolus (n = 6), and primary and secondary arterial thrombosis (n = 8). Duration of occlusion was less than 24 hours in seven, 1 to 7 days in ten, and more than 7 days in ten patients. Twelve (44.44%) patients had complete clot lysis, four (14.81%) had partial clearance, and 1 1 (40.74%) remained occluded. Eight (29.63%) had serious complications including one death. Eighteen (66.66%) patients needed further surgical intervention to maintain graft patency. Data were analyzed using the chi-square and pooled t test. No significant difference was observed in results from thrombolysis from different conduits, gender, etiology, or smoking history. Increased duration of tPA administration was associated with an increased risk of failure. Administration of total dosages greater than 60 mg was associated with a higher risk of failure. Diabetics had a poor outcome (p=0.0520). Only 44% of patients successfully underwent lysis. A primary surgical option may be a more sensible course than lysis, given that the vast majority of patients ended up having surgery anyway.

Aorto—Left Renal Vein Fistula: Is There a Place for Endovascular Management?

Purpose:

To describe the endovascular treatment of an aorto-left renal vein fistula.

Methods and Results:

A 77-year-old man with multiple comorbidities presented with low back pain, hematuria, cyanosis, and a pulsatile abdominal mass. Imaging confirmed a 7-cm abdominal aortic aneurysm with a contained rupture into the left renal vein. Owing to the patient's high surgical risk, a Talent Endoluminal Stent-Graft was implanted to satisfactorily exclude the aneurysm. Hemodynamic stability and normal renal function were restored; however, continued perfusion of the sac prompted an attempt to percutaneously repair the renal vein defect. This effort failed, so open laparotomy was necessary.

Conclusions:

Although total endovascular management was not successful in this case, the initial use of a minimally invasive approach allowed the patient's clinical status to improve and lower the risk of subsequent surgery.

Evolution of Carotid Surgical Practice in the last Decade

Stroke units provide immediate care and appropriate intervention in the evolving stroke. The aims of this study were to review the practice of carotid endarterectomy (CEA) before and after the establishment of a Stroke Unit in St. James's Hospital. Prior to the introduction of the Stroke Unit, 263 CEA's were performed over a five-year period. 139/263 (53%) of these were for symptomatic disease. 229 were performed in the five years since. 179/229 (78%) of these were for symptomatic disease. The 30-day stroke and death rates were < 2% before the introduction of the Stroke Unit, and have remained unchanged. Since the introduction of the Stroke Unit, there has been a slight decrease in the overall number of CEA's performed with a 25% increase in the proportion of endarterectomies performed for symptomatic disease. Despite the reduction in surgery for asymptomatic disease the overall 30-day stroke and death rate remains excellent at 2/229 (2%).

Increased thrombin generation potential in symptomatic versus asymptomatic moderate or severe carotid stenosis and relationship with cerebral microemboli

INTRODUCTION

The importance of thrombin generation in the pathogenesis of TIA or stroke and its relationship with cerebral microembolic signals (MES) in asymptomatic and symptomatic carotid stenosis has not been comprehensively assessed.

METHODS

Plasma thrombin generation parameters from patients with moderate or severe (≥ 50%) asymptomatic carotid stenosis were compared with those from patients with symptomatic carotid stenosis in the early (≤ 4 weeks) and late phases (≥ 3 months) after TIA or stroke in this prospective, pilot observational study. Thrombin generation profile was longitudinally assessed in symptomatic patients with data at each time point. Bilateral transcranial Doppler ultrasound monitoring of the middle cerebral arteries was performed whenever possible to classify patients as MES-positive or MES-negative.

RESULTS

Data from 31 asymptomatic, 46 'early symptomatic' and 35 'late symptomatic' patients were analysed. Peak thrombin (344.2 nM vs 305.3 nM; p = 0.01) and endogenous thrombin potential (1772.4 vs 1589.7; p = 0.047) were higher in early symptomatic than asymptomatic patients. Peak thrombin production decreased in symptomatic patients followed up from the early to late phase after TIA or stroke (339.7 nM vs 308.6 nM; p = 0.02). Transcranial Doppler ultrasound data were available in 25 asymptomatic, 31 early symptomatic and 27 late symptomatic patients. Early symptomatic MES-positive patients had a shorter 'time-to-peak thrombin' than asymptomatic MES-positive patients (p=0.04), suggesting a more procoagulant state in this early symptomatic subgroup.

DISCUSSION

Thrombin generation potential is greater in patients with recently symptomatic than asymptomatic carotid stenosis, and decreases over time following TIA or stroke associated with carotid stenosis. These data improve our understanding of the haemostatic/thrombotic biomarker profile in moderate-severe carotid stenosis.

Fenestrated endovascular repair of complex aortic aneurysms

BACKGROUND

Fenestrated endovascular aneurysm repair (FEVAR) provides an endovascular solution for patients with large abdominal aortic aneurysms and challenging neck anatomy in addition to repair of endoleaks and pseudoaneurysms. This article reports the midterm outcomes of FEVAR from a single-tertiary referral centre in Ireland.

METHODS

From 2006 to 2012, nine consecutive asymptomatic patients with neck anatomy unfavourable for standard EVAR underwent endovascular repair with a customised fenestrated Zenith stent graft. An additional three patients had fenestrated grafts for repair of pseudoaneurysms (n = 2) following open AAA repair and a type I endoleak (n = 1). All patients were prospectively enrolled in a computerised database. Outcomes including mortality, morbidity, renal function, target vessel patency, endoleak and reintervention were analysed.

FINDINGS

The mean age and aneurysm size in the primary repair group were 74 years (65-84 years) and 6 cm (5-8.3 cm), respectively, and in the secondary repair group, the mean age was 66 years (61-75 years). No procedures required open conversion, and no visceral arteries were lost. On completion angiography, two patients in group 1 had a type I endoleak and one had a type III endoleak. There were no endoleaks in the secondary repair group. Follow-up ranged from 30 days to 6 years. There was one death within 30 days (8 %) and two deaths at 3 years from non-aneurysm-related causes. Six patients required secondary interventions. Three patients had a transient post-operative creatinine rise of >30 %.

CONCLUSION

Our study supports FEVAR as a feasible and effective therapy in the management of patients with complex aortic aneurysms.

Increased platelet activation in early symptomatic vs. asymptomatic carotid stenosis and relationship with microembolic status: results from the Platelets and Carotid Stenosis Study

BACKGROUND

Cerebral microembolic signals (MES) may predict increased stroke risk in carotid stenosis. However, the relationship between platelet counts or platelet activation status and MES in symptomatic vs. asymptomatic carotid stenosis has not been comprehensively assessed.

SETTING

University teaching hospitals.

METHODS

This prospective, pilot observational study assessed platelet counts and platelet activation status, and the relationship between platelet activation and MES in asymptomatic vs. early (≤ 4 weeks after TIA/stroke) and late phase (≥ 3 months) symptomatic moderate or severe (≥ 50%) carotid stenosis patients. Full blood count measurements were performed, and whole blood flow cytometry was used to quantify platelet surface activation marker expression (CD62P and CD63) and circulating leucocyte-platelet complexes. Bilateral simultaneous transcranial Doppler ultrasound monitoring of the middle cerebral arteries was performed for 1 h to classify patients as MES positive or MES negative.

RESULTS

Data from 31 asymptomatic patients were compared with 46 symptomatic patients in the early phase, and 35 of these patients were followed up to the late phase after symptom onset. The median platelet count (211 vs. 200 × 10(9)  L(-1) ; P = 0.03) and the median percentage of lymphocyte-platelet complexes was higher in early symptomatic than asymptomatic patients (2.8 vs. 2.4%; P = 0.001). The percentage of lymphocyte-platelet complexes was higher in early symptomatic than in asymptomatic patients with ≥ 70% carotid stenosis (P = 0.0005) and symptomatic patients recruited within 7 days of symptom onset (P = 0.028). Complete TCD data were available in 25 asymptomatic, 31 early phase symptomatic and 27 late phase symptomatic patients. Twelve per cent of asymptomatic vs. 32% of early phase symptomatic (P = 0.02) and 19% of late phase symptomatic patients (P = 0.2) were MES positive. Early symptomatic MES-negative patients had a higher percentage of lymphocyte-platelet complexes than asymptomatic MES-negative patients (2.8 vs. 2.3%; P = 0.0085).

DISCUSSION

Recently, symptomatic carotid stenosis patients have had higher platelet counts (potentially reflecting increased platelet production, mobilization or reduced clearance) and platelet activation status than asymptomatic patients. MES were more frequently detected in early symptomatic than asymptomatic patients, but the differences between late symptomatic and asymptomatic groups were not significant. Increased lymphocyte-platelet complex formation in recently symptomatic vs. asymptomatic MES-negative patients indicates enhanced platelet activation in this early symptomatic subgroup. Platelet biomarkers, in combination with TCD, have the potential to aid risk-stratification in asymptomatic and symptomatic carotid stenosis patients.

Endovascular repair of thoracoabdominal aortic aneurysm (TAAA): early experience

BACKGROUND

Repair of thoracoabdominal aortic aneurysms (TAAA) represents a considerable technical challenge. Since its first description in 1955, open repair of TAAA has been considered the gold standard of repair. Despite improvements in surgical techniques, spinal cord protection and post-operative critical care support, patients who undergo open repair are faced with a mortality rate of 5-35 %. We report the first Irish experience of endovascular management of TAAAs.

RESULTS

To date five patients have undergone endovascular repair; four had hybrid repair and one a fenestrated graft. The mean age of the patients was 66.8 ± 3.4 and the mean aneurysm diameter was 6.74 ± 0.6 cm. All patients were ASA III. Two-stage hybrid repair was associated with an increased risk of complications, prolonged intensive care unit and overall hospital stay. One patient died in the perioperative period due to rupture of their aneurysm between the two stages of their hybrid repair.

CONCLUSION

The role of endovascular techniques in the treatment of TAAA continues to evolve. Hybrid and complete endovascular repairs do not replace conventional repair, but provide an alternative for high-risk patients who might otherwise be denied treatment.

A critical evaluation of HIPE data

Resource allocation and planning of future services is dependent on current volumes, making it imperative that procedural data is accurately recorded. We sought to evaluate the effectiveness of the information gathered by the Hospital Inpatient Enquiry (HIPE) system in recording such activity. Five index vascular procedures (open/endovascular abdominal aneurysm repair, carotid endarterectomy, lower limb angioplasty/bypass) were chosen to reflect activity. The Economic and Social Research Institute (ESRI), and HIPE databases were interrogated to obtain the regional and hospital specific figures for the years 2005, 2006 and 2009, and then compared with the prospective vascular database in St James's hospital. Data for 2006 (the most recent year available) shows significant discrepancies between the HIPE and vascular database figures for St James's hospital. The HIPE and database figures respectively for; open aneurysm 13/30 (-50%), endovascular aneurysm 39/31 (+25%), carotid 62/48 (+29%), angioplasty 242/111 (+100%) and bypass 24/10 (+100%) These inaccuracies are likely to be magnified on a regional and national level when pooling data.

Endovascular management of thoracic aortic pathology

BACKGROUND

Endovascular technology has revolutionised the management of abdominal aortic aneurysmal disease but the less frequent occurrence of pathology in the thoracic aorta has meant that evidence demonstrating the primacy of endovascular treatment strategies in this portion of the vessel is less convincing. Herein we summarise the best available evidence to date.

METHODS

A comprehensive search of the surgical and radiological literature using the search term 'endovascular thoracic aorta' was conducted.

FINDINGS AND CONCLUSIONS

The vast majority of patients treated by thoracic aortic stent grafting have had their treatment outside the context of a randomised trial. While it would seem that endovascular repair is the treatment of choice for the thoracic aorta, the present evidence is based on single centre case series and is anecdotal at best.

Prospective randomized controlled trial: conventional versus powered phlebectomy

OBJECTIVES

Transilluminated powered phlebectomy (TriVex) is a new surgical technique that uses tumescent dissection, transillumination, and powered phlebectomy. The purpose of this study was to compare TriVex with conventional varicose vein surgery in terms of pain, cosmesis, recurrence, complications, and operating time.

METHODS

One hundred eighty-eight limbs in 141 patients (33 men, 108 women; mean age, 42.5 years) with varicose veins were randomised to conventional (n = 100) or TriVex (n = 88). Exclusion criteria were venous ulceration or deep venous disease. Varicosities were graded with CEAP and clinical assessment (grades 1-3), and were similar in both groups. Randomization was single blinded. Long or short saphenous vein ligation or stripping was performed as indicated with duplex scanning. Operative time was from skin incision to leg bandaging. Phlebectomy was performed with conventional stab avulsions or TriVex. Patients completed assessment forms preoperatively and postoperatively (2, 6, 26, 52 weeks), and this was supplemented with physician clinical evaluation. Pain was assessed with visual analog score.

RESULTS

There was a significant difference in the number of incisions for phlebectomy in the two groups (conventional, n = 29; TriVex, n = 5; P <.0001). TriVex was faster in the grade 3 (extensive) group, but this did not reach statistical significance. There was no difference in mean postoperative pain score over 8 days in the two groups (P =.4624). At 2 weeks there was no significant difference between the groups with regard to bruising (P =.77), cellulitis (P =.33), and numbness (P =.33). At 6 weeks there was no significant difference between the groups with regard to nerve injury (P =.97), residual veins (P =.79), cosmetic score (P =.837), and overall satisfaction (P =.878). At 6 and 12 months, there was no significant difference in cosmesis (P =.955, P =.088, respectively) or recurrence (P =.27, P =.11, respectively).

CONCLUSIONS

TriVex is a safe and effective method for excision of varicosities and compares well, after a learning curve, with conventional surgery in regard to complications and recurrence. It has the advantage of a trend toward reduced operating time in extensive varicosities, and significantly fewer incisions, although there was no perceived difference in cosmesis during follow-up.

Impact of angioplasty on infrainguinal bypass for critical ischaemia of the leg

Background

Both angioplasty and infrainguinal bypass procedures may be used to achieve limb salvage in patients with critical ischaemia. The authors investigated the effect of the introduction of angioplasty on the frequency with which infrainguinal bypass was performed and, second, the changes in outcome of infrainguinal bypass following the introduction of angioplasty.

Methods

All patients had critical ischaemia of the leg. Three patient groups were studied: 215 patients undergoing infrainguinal bypass before the introduction of angioplasty (1986–1991), 216 patients who had infrainguinal bypass after the introduction of angioplasty (1993–1998) and 193 patients undergoing angioplasty in the same 5-year interval (1993–1998).

Results

The age and risk profile of the three groups was identical. The overall caseload increased by 19 per cent following the introduction of angioplasty. Primary and secondary patency rates were superior for bypass compared with angioplasty, but were similar for the two bypass groups (5-year primary patency rate 60 per cent versus 18-month primary patency rate 45 per cent; 5-year secondary patency rate 80 per cent versus 18-month secondary patency rate 60 per cent). By 18 months 26 per cent of patients having angioplasty had gone on to have bypass. The limb salvage rate of 90 per cent at 1 year was similar for all groups. Survival was significantly higher in the group of patients undergoing bypass from 1993 to 1998 compared with the other two groups (80 versus 60 per cent; P &lt; 0·0002).

Conclusion

The introduction of angioplasty has increased overall workload. Angioplasty has a lower patency rate than bypass but a comparable limb salvage rate, making it a suitable alternative to bypass in the management of patients with critical ischaemia.

Ultrasound guided human thrombin injection. A new modality in the management of femoral artery pseudo-aneurysms

OBJECTIVES

We report our initial results of a prospective study of duplex ultrasound-guided injection (UGTI ) of thrombin in the management of femoral artery pseudo-aneurysms. We used human thrombin to avoid the increase in the human antibodies directed against fibrinogen, with the use of bovine thrombus, that preclude further utilisation of the bovine fibrin glue during cardio-thoracic surgery.

METHODS

From 1999 to 2001, 19 patients, aged 69 (range 52-85) years presented with 21 femoral pseudo-aneurysms were treated. The mean pseudoaneurysm diameter was 30 (15-55) mm. All but two were secondary to cardiac procedures and the common femoral artery was the injured vessel in all instances. Patients were referred within 2-21 days following their iatrogenic injury.

RESULTS

Immediate thrombosis of the sac occurred in 19 (90%) of the 21 pseudo-aneurysms. After a second injection, complete occlusion occurred in the remaining two patients. Two patients (CI 95%; 1-19) with three femoral pseudo-aneurysms developed leg pain. Duplex ultrasound follow-up showed two recurrences (9.5% - CI 95%; 1-19) and both were treated by repeat UGTI. There was no conversion to surgical repair.

CONCLUSION

This percutaneous minimally invasive technique is safe and effective in the management of iatrogenic pseudo-aneurysms in this high-risk group of patients. Human thrombin has significant advantages over bovine thrombin.

Arcuate-legged nonpenetrating vascular closure staples (VCS): early experience

Vascular closure staples (VCS) provide a novel technique for fashioning vascular anastomoses, allowing a single operator to perform suture-less anastomoses. They may be used primarily or in an adjuvant role. When VCS are compared to a running suture, advantages include the avoidance of intimal damage, platelet aggregation and intimal hyperplasia at the anastomotic suture line, and a shorter time taken to complete the anastomosis. We report our early experience using VCS in an array of vascular anastomoses and conclude that VCS are a useful addition to the vascular surgeon's armamentarium. They help to decrease the time taken to construct an anastomosis, and are particularly useful in an adjuvant setting, complementing conventionally placed sutures.

Endoluminal stent grafts in the management of infrarenal abdominal aortic aneurysms: a realistic assessment

OBJECTIVES

transfemoral endoluminal aortic management (TEAM) is technically feasible in the treatment of infrarenal abdominal aortic aneurysms but its advantage over conventional repair is unproved. We report our initial experience, learning curve and technical difficulties encountered during the process of establishing this novel technique in our institute.

MATERIAL AND METHODS

over a 3-year period 400 cases of abdominal aortic aneurysms were reviewed; only 58 cases (15%) were suitable for endovascular repair under our TEAM protocol and 36 (9%) were offered endovascular intervention. They were mainly high-risk patients (85% ASA III and IV) with a mean age of 72 years. Thirty-three bifurcated grafts, two straight tube grafts and one aorto mono-iliac graft were deployed. We oversized the graft by 15-20% to the diameter of the aortic neck and both common iliac arteries.

RESULTS

two cases (6%-95% CI: 1-19%) had on-table conversion because of ruptured common iliac arteries. Peri-operatively there were two deaths from multi-organ failure. Transient renal failure occurred in two patients and three patients (9%) suffered a non-fatal myocardial infarction. Sixteen percent of patients had a groin wound problem. The mean hospital stay was 7 days. Five minor endoleaks (15%) were identified and sealed at 30 days. One secondary endoleak was identified at 18 months because of a patent juxta-renal lumbar artery. No secondary cuffs or extensions were used. Mean follow-up was 29 months and all grafts remained patent. The technical, clinical, continuous and secondary success rates were 78%, 91%, 89% and 91% respectively with TEAM.

CONCLUSION

endovascular training, patient selection and learning curve impose an impact on the final outcome. Until a reliable hard point is reached so that endovascular repair could be exercised in routine practice, the use of TEAM must be questioned in high-risk patients, and should be performed under clinical trial conditions using strict selection criteria.

Suprarenal mycotic aneurysm exclusion using a stent with a partial autologous covering

PURPOSE

To report a combined endovascular and open technique to manage a suprarenal mycotic aortic aneurysm using a stent-graft partially covered with a section of autologous artery.

METHODS AND RESULTS

A 50-year-old was hospitalized for staphylococcal septicemia and severe back pain. A previously diagnosed 3-cm abdominal aortic aneurysm was found to have expanded 2 cm in 3 weeks. Aortography documented some periaortic thickening and 2 mycotic aneurysms, one posterior at the level of the superior mesenteric artery and the second at the aortic bifurcation. After intensive antibiotic therapy, an endovascular approach to exclude the suprarenal mycotic aneurysm was undertaken in tandem with surgical excision of the infrarenal aneurysm. The harvested right common iliac artery was used to partially cover a Palmaz stent, which was deployed under direct vision just above the renal artery ostia so that the covered portion of the stent excluded the aneurysm. A right axillofemoral bypass with a femorofemoral bypass completed the revascularization. Postoperatively, the patient developed renal failure, ischemic colitis necessitating a left hemicolectomy, and paraplegia. Although the patient is paralyzed, the aneurysm remains excluded with patent visceral vessels at 12 months following surgery. No organisms were grown from excised aortic tissue, and no signs of recurrent infection have been seen.

CONCLUSIONS

Stent-graft repair may be able to lessen the invasiveness and reduce the morbidity associated with treatment of mycotic aortic aneurysms.

Endovascular management of rare sciatic artery aneurysm

PURPOSE

To present a rare case of complete persistent sciatic artery aneurysm successfully treated by coil embolization and to suggest a new classification for this anomaly that encompasses both clinical and pathological factors.

METHODS AND RESULTS

A 77-year-old female presented with sudden onset of sharp, throbbing left thigh and foot pain. A nontender 10.0- x 7.0-cm pulsatile mass was found over the inferolateral aspect of the left buttock on examination in the right lateral decubitus position. Angiography demonstrated a 6.9-cm sciatic artery aneurysm with the distal sciatic artery completely thrombosed. Before planned bypass grafting, the aneurysm and distal segment of the internal iliac artery were successfully embolized with coils through a left percutaneous approach. The patient's symptoms resolved with no deterioration in limb perfusion, and further revascularization was unnecessary. Postembolization imaging showed complete occlusion of the aneurysm, which has continued for 19 months.

CONCLUSIONS

The application of endovascular techniques and surgical revascularization procedures provides numerous management options for the treatment of an aneurysmal persistent sciatic artery. This case demonstrates that clinical evaluation between staged procedures may obviate the need for further intervention.

Tibial and peroneal artery bypasses using polytetrafluoroethylene (PTFE) with an interposition vein cuff

The combined results of femoro-distal bypasses using prosthetic material with vein cuffs from two separate vascular units is presented.

METHOD

Over the last five years, 89 infrainguinal bypasses using polytetrafluoroethylene (PTFE) with a distal interposition vein cuff to a tibial artery have been performed in two centres. All operations were for critical limb ischaemia. The mean age was 72 years (47-90), there were 46 males and 43 females, 27 of whom were diabetic. Twenty-eight patients had a history of angina and/or previous myocardial infarct. The median follow-up was 12 months (0-68 months).

RESULTS

During the follow-up period there were 28 deaths, 35 major limb amputations and 44 graft failures. The graft patency rates at 12 and 24 months were 50 and 32%, and limb salvage rates were 53 and 44%, respectively. The patient survival rates were 66 and 61%, respectively.

CONCLUSION

The authors believe that the likely improvement in pain free quality of life the patient may enjoy with a successful bypass shifts the balance in some individuals towards bypass surgery using PTFE with a vein cuff to a tibial artery when such an option is possible.

Fifteen-year experience of transperitoneal management of inflammatory abdominal aortic aneurysms

OBJECTIVES

to assess the long-term outcome of patients with inflammatory abdominal aortic aneurysms.

MATERIALS AND METHODS

over a fifteen-year period 598 cases of abdominal aortic aneurysm were treated and, of these, 32 cases (5.3%) were inflammatory in nature. The diagnosis was made on preoperative (CT) computed tomography in fifteen cases. Twenty-six patients were symptomatic on presentation and ten cases were repaired on an emergency basis. Only six were repaired electively. The transabdominal transaortic approach without dissection on the nearby adherent structures was used routinely.

RESULTS

there was one postoperative death from a respiratory arrest leading to a thirty-day mortality of 3.1%. Early graft thrombosis occurred in three cases (9.3%) and all underwent successful thrombectomy. Colonic ischaemia was encountered in one patient who later developed an aortoenteric fistula. Two patients suffered a non-fatal myocardial infarction postoperatively leading to an overall morbidity of 18.7%.

CONCLUSIONS

patients with inflammatory aortic aneurysms fare worse than patients with aortic aneurysms in general. Preoperative suspicion assists in planning surgery. We believe that the transperitoneal approach with an anterolateral aortotomy and minimal dissection of adherent structures offers excellent results in dealing with this difficult group of patients.

Aorto-left renal vein fistula: is there a place for endovascular management?

PURPOSE

To describe the endovascular treatment of an aorto-left renal vein fistula.

METHODS AND RESULTS

A 77-year-old man with multiple comorbidities presented with low back pain, hematuria, cyanosis, and a pulsatile abdominal mass. Imaging confirmed a 7-cm abdominal aortic aneurysm with a contained rupture into the left renal vein. Owing to the patient's high surgical risk, a Talent Endoluminal Stent-Graft was implanted to satisfactorily exclude the aneurysm. Hemodynamic stability and normal renal function were restored; however, continued perfusion of the sac prompted an attempt to percutaneously repair the renal vein defect. This effort failed, so open laparotomy was necessary.

CONCLUSIONS

Although total endovascular management was not successful in this case, the initial use of a minimally invasive approach allowed the patient's clinical status to improve and lower the risk of subsequent surgery.

Outcome of the first 100 femoropopliteal angioplasties performed in the operating theatre

OBJECTIVES

To examine the factors influencing outcome and restenosis in an initial series of 100 infrainguinal angioplasties.

DESIGN

Prospective study of angioplasties of the superficial femoral and popliteal arteries performed over a 42-month period.

MATERIALS AND METHODS

One hundred consecutive angioplasties in 96 patients performed in the operating theatre between January 1993 and June 1996 were followed prospectively with clinical, ABI, and duplex assessment. Forty-four procedures were for disabling claudication and 56 for critical ischaemia. Stents were deployed in 30 limbs.

RESULTS

Angioplasty was successful in 84 of 100 limbs. Cumulative patency of the entire group at 3, 6, 12 and 18 months was 78%, 60%, 53%, and 49% respectively, while excluding initial failures, gave patencies of 95%, 69%, 63%, and 58%, respectively. Claudicants with a 1-year patency of 64% did significantly better than patients with critical ischaemia (44% p < 0.05). Angioplasties performed during the initial 21 months had a 1-year patency of 42%, while those performed in the final 21 months had a 74% patency (p = N.S.). The patency for stented arteries was 66% vs. 49% for angioplasty alone (p = N.S.). The 2-year limb salvage rate was 91% in patents with critical ischaemia. Forty-six per cent of restenoses were asymptomatic.

CONCLUSIONS

The results suggest that while angioplasty is useful in treating infrainguinal arterial disease, there is a learning curve, resulting in a high restenosis rate for occlusive and multilevel disease, while concomitant placement of stents may be beneficial.

Popliteal aneurysms: a 10-year experience

BACKGROUND

Popliteal aneurysms account for 70% of peripheral arterial aneurysms and, if untreated, pose a serious threat to the affected limb. Debate continues about the best form of treatment especially for asymptomatic lesions.

METHOD

We reviewed the computer records and charts of patients seen at this department with a diagnosis of popliteal aneurysm over the last 10 years. Patients who had not been seen within the last year were followed-up through their G.P.

RESULTS

Twenty-four patients (M 23/F 1) presented with 40 popliteal aneurysms. The mean age was 63.5 +/- 9 years. Symptoms were present in 23 of the affected limbs while 17 were asymptomatic. Thirty were treated surgically and 10 followed with regular ultrasound. The mean diameter of the repaired aneurysms was 3.3 +/- 1 cm. Aneurysms < 2 cm were more likely to be asymptomatic. No limbs were lost in patients undergoing elective repair of popliteal aneurysms. The secondary patency and limb salvage rates at 3 years were 84% and 96% respectively. Conservative management of asymptomatic lesions < 2 cm was not complicated by the development of symptoms.

CONCLUSIONS

Elective repair of popliteal aneurysms by exclusion and bypass is a safe, effective and durable technique. Small asymptomatic lesions can be safely managed with close follow-up.

Results and lessons to be learned from a waiting list initiative

Varicose veins are a major and increasing burden on the health service with waiting lists growing in the majority of units. Most successive Governments have funded waiting list initiatives to deal with this problem. We report the results of a one year varicose vein waiting list initiative which dealt with a total of 1104 patients. A standard triage regime was established. Two hundred and eighty five patients were removed from the waiting list due to failure to attend, surgery performed elsewhere, medically unfit or no longer wishing to have surgery. There were 63 late cancellations and 23 operations were cancelled following admission due to unrelated medical complications. Planned operating lists worked well and complications were uncommon. Several important lessons were learnt during this initiative and recommendations are made with regard to the optimal method of dealing with the problem of varicose veins.

Recurrent varicose veins

Recurrence of varicose veins after treatment has been reported as being between 7% and 65%. During the five month period from August to December 1993, 400 operations on 265 patients were performed for varicose vein disease. Of these, 53 patients had presented with recurrent vein disease in 72 limbs (18%). All patients underwent Duplex scanning of their deep and superficial systems and sites of venous incompetence were identified. The sapheno-femoral junction (SFJ) was found to be incompetent in 52 limbs, of which 31 had previously undergone flush ligation. Sapheno-popliteal junction (SPJ) was incompetent in 33 limbs, while the long saphenous vein (LSV) was found to be incompetent in 67 cases. There were no major complications in this group. Minor complications occurred in 10 cases (14%), mainly in the form of thigh paraesthesia. The more common causes of recurrent disease have been identified and therefore, it should be possible to reduce its incidence. Duplex scanning is essential for any unit dealing with recurrence.

Lower extremity bypass for critical ischemia using synthetic conduit and adjuvant vein cuff

The use of an interposition cuff of vein placed at the distal anastomosis between synthetic bypass conduit and outflow vessel has been advocated to improve patency of lower extremity bypass grafts. Over a three-year period we have performed 43 such bypass procedures: to the above knee popliteal artery (n = 3); below knee popliteal (n = 13), and infrapopliteal arteries (n = 27). There were 20 females and 23 males having a mean age of 70 years (48-84 years). Fifteen patients were hypertensive, 15 were diabetic, and 25 had a history of tobacco use. All cases required limb salvage for rest pain (n = 25), gangrene (n = 10), or ulceration (n = 8) in the absence of suitable autologous vein. Nineteen operations followed a previous failed bypass. Patients were reviewed at six-month intervals. The operative mortality was 8% and two-year primary and secondary patency were 40% and 55%, respectively. Cumulative patency rates were better for first-time grafting procedures than for patients who had undergone previous attempts at limb salvage (60% versus 22%). Two-year limb salvage was 60%. During the same time period, two-year primary and secondary patency rates were 54% and 67%, respectively for autogenous vein. Although the numbers are small these results support the use of an adjuvant vein cuff when employing synthetic grafts. A prospective study of vein versus synthetic graft plus cuff should be undertaken.

Alpha 2C-adrenoceptors mediate contractile responses to noradrenaline in the human saphenous vein

We have investigated the subtype of alpha 2-adrenoceptor mediating isometric contractions of human saphenous vein in comparison with alpha 2-adrenoceptor ligand binding sites. Postjunctional alpha 2-adrenoceptors in the human saphenous vein were investigated in terms of the ability of alpha 2-adrenoceptor antagonists to shift the contractile potency of noradrenaline. The following antagonists were employed (potencies, pKB, in human saphenous vein in parentheses): chlorpromazine (6.98 +/- 0.24), BDF 8933 (7.60 +/- 0.06), prazosin (6.62 +/- 0.15), ARC 239 (7.19 +/- 0.15), yohimbine (7.23 +/- 0.09), HV 723 (7.52 +/- 0.14), WB 4101 (7.90 +/- 0.06), SKF 104078 (6.55 +/- 0.08), BRL 44408 (5.72 +/- 0.21). Antagonist potency at postjunctional alpha 2-adrenoceptors was correlated with antagonist affinity at alpha 2-adrenoceptor ligand binding sites in membranes of human platelet (alpha 2A), rat kidney (alpha 2B) and Sf9 cells expressing human recombinant receptors (alpha 2C), labelled with [3H]yohimbine. The correlation with the postjunctional alpha 2-adrenoceptor mediating contraction of the human saphenous vein was best for the human recombinant alpha 2C-adrenoceptor ligand binding site (r = 0.92, n = 8, P < 0.001), as compared to correlations with the alpha 2B-adrenoceptor ligand binding site of rat kidney (r = 0.62, n = 8, n.s.) and with the alpha 2A-adrenoceptor ligand binding site of human platelet (r = 0.23, n = 8, n.s.). It is concluded that the functional postjunctional alpha 2-adrenoceptor mediating contractions of the human saphenous vein closely resembles the human recombinant alpha 2C-adrenoceptor ligand binding site.

Skin closure and the incidence of groin wound infection: a prospective study

Groin wound infection is a dreaded complication of vascular surgery and may jeopardize an underlying graft. A variety of skin closures have been used and the object of this study was to prospectively determine the relationship between skin closure and wound infection. One hundred fourteen consecutive patients (70 men and 44 women) undergoing bypass surgery with a groin incision (n = 173) were randomly assigned to skin closure with subcuticular Maxon, interrupted nylon, continuous nylon, or clips following a standard two-layer closure of subcutaneous tissue. Fourteen (12%) patients had diabetes and 50 (44%) had digital ulceration and gangrene. Aortofemoral bypass was performed in 25% of the patients and infrainguinal bypass in the remaining 75%. Perioperative wound cultures were obtained before closure. Wounds were inspected and cultures repeated on postoperative days 3, 5, 7, 10, and 14. Infection was defined as a positive culture. Groin wound infection occurred in 3% of the population and graft infection in 0.6%. The type of suture did not influence the incidence of infection. This study failed to demonstrate a significant difference in the incidence of wound infection with the use of different suture materials. We conclude that suture material should be selected on the basis of surgeon preference and costs.

Arterial closing pressure correlates with diastolic pseudohypertension in the elderly

BACKGROUND

Pseudohypertension has frequently been reported in the elderly population, with the diastolic measurement being the most frequent source of error. There is no satisfactory noninvasive method of calculating the error in the blood pressure reading. We investigated the role of arterial closing pressure in the diagnosis of diastolic pseudohypertension.

METHODS

Indirect and direct blood pressure were measured in 24 elderly patients. Brachial artery closure was visualized by ultrasound in all subjects. Arterial closing pressure (ACP) was recorded as zero if the vessel was seen to close spontaneously when it was isolated from central arterial pressure. If the vessel did not close spontaneously, a water cuff was applied externally over the artery and the additional pressure required to close it was recorded.

RESULTS

Diastolic pseudohypertension was noted in 8 subjects. Spontaneous closure of the brachial artery occurred in the 16 without pseudohypertension; i.e., ACP = 0. Additional pressure of the water cuff (range: 30-158 mm Hg) was required to collapse the artery (ACP) in those with diastolic pseudohypertension. ACP correlated with the extent of diastolic pseudohypertension (range: 5-17 mm Hg); r = .85, p < .001).

CONCLUSION

We propose that ACP may be used to diagnose the presence and extent of pseudohypertension.

Pentoxifylline and critical leg ischemia

The annual incidence of critical leg ischemia has been estimated at 500-1,000 patients per million population/year. In critical ischemia there is a breakdown in the microvascular flow-regulating system and inappropriate activation of the microvascular defense system, with resultant endothelial damage and activation of platelets and leukocytes, which leads to further damage of the capillary network. The mainstay of treatment until recently has consisted of interventional procedures. However, these are not always feasible and are not without significant mortality and morbidity. Therefore, attention has been directed towards pharmacologic management. Pentoxifylline inhibits leukocyte aggregation and activation, and improves red cell deformability and oxygen release to tissue. On the basis of these properties, several pilot studies were undertaken, and most have confirmed the benefits of pentoxifylline in the management of critical ischemia. These positive results led to the initiation of a multicenter, double-blind, placebo-controlled study of intravenous pentoxifylline in the acute management of critical ischemia. Results showed a significant reduction in rest pain with pentoxifylline, and outcome was not influenced by various prognostic factors. Research to date suggests that pentoxifylline could have a definite role in the management of patients with critical ischemia.

Improved limb salvage and mobility following peroneal artery bypass

During the 10-year period August 1981 to 1991, 92 consecutive patients underwent revascularisation to the peroneal artery (40 to the upper third, 30 to the mid and 22 to the distal third). The male/female ratio was 1.6:1 and the mean age was 72 years. Thirteen patients had independent mobility preoperatively while 58 had limited mobility and the remaining 18 were bed/housebound. Following surgery the patients were prospectively evaluated and mean follow-up was 25 months. The 1 and 3 year patency rates were 67 and 59% respectively and cumulative limb salvage rates were 75 and 71%. Forty-four patients returned to independent mobility while 36 had limited mobility and 11 remained housebound. Reconstruction to the peroneal artery is a valuable adjuvant for limb salvage providing satisfactory cumulative patency and facilitating improved mobility.

The comparison of type of incision for transperitoneal abdominal aortic surgery based on postoperative respiratory complications and morbidity

Equal access to the abdominal aorta can be attained through midline and transverse abdominal incisions. The surgical literature suggests that transverse incisions cause less postoperative pain and morbidity. Fifty patients (10 females and 40 males, mean age 67 years) undergoing abdominal aortic surgery were randomised to a midline (n = 25) or transverse (n = 25) incision. All patients were evaluated preoperatively and postoperatively for seven days. Changes in pulmonary function (FVC and FEV1), time to open and close the incision, analgesia used (morphine mg/kg/h), clinical or X-ray evidence of chest infection, and the duration of ICU stay were recorded. In the transverse group there was a reduction in the incidence of chest complications (20% vs. 28%, p = ns) and these incisions took longer to open (13.9 +/- 4.6 vs. 9.9 +/- 5.1, p < 0.05), but overall there was no significant difference between any other parameter in the two groups. Our results show no statistically significant difference in morbidity or analgesia consumption following transverse or midline abdominal incisions and we conclude that the type of incision used can be left to the surgeon's preference.

Contralateral stenosis and stump pressures: parameters to identify the high risk patient undergoing carotid endarterectomy under local anaesthesia

Carotid endarterectomy (CEA) under local anaesthesia (LA) enables the assessment of the two parameters of stump pressure and contralateral stenosis as predictors of neurological complications both intra- and postoperatively. Over a 7 year period, 175 carotid endarterectomies were performed under LA and of these, stump pressure measurements and angiographic findings were recorded on 99 patients. There were no deaths, two patients (2.0%) suffered a perioperative stroke (CVA) and one (1.0%) a transient ischaemic attack (TIA). An additional eight patients "obtunded" while the internal carotid artery was clamped, with complete resolution upon revascularisation in all but one patient who recovered fully within 24 h. Patients with contralateral occlusion or > or = 80% stenosis were more likely to develop complications (6/25 vs. 5/74 p < 0.03) and stump pressures were significantly lower in patients suffering an event (34.36 +/- 23.15 vs. 55.57 +/- 27.58, p < 0.02). By combining contralateral stenosis (> or = 80%) and stump pressure (< or = 35 mmHg), a "high risk" group of 42 patients in whom eight of the 11 events occurred, were identified. Contralateral stenosis and low stump pressures can be used in combination to identify high risk patients likely to develop neurological complications during or following CEA.

New approaches in the medical management of venous ulceration

This literature survey of the medical treatment of venous ulcers of the lower extremities discusses five classes of agents: (1) fibrinolytics, (2) hydroxyrutosides, (3) prostaglandins, (4) methylxanthines, and (5) others. The authors conclude that all these agents require further research.

Observing the brachial artery through a pressure cuff

A technique is described which enables ultrasonic imaging of the brachial artery whilst pressure is applied via a pressure cuff. This involves a new instrument--a sphygmomanometer, which uses water as opposed to air as the pressure medium, in order to permit ultrasonic imaging through the cuff. The technique was found to be acceptable in the clinical setting, and gave a measurement of the systolic blood pressure which correlated with the conventional cuff measurement in eleven elderly subjects (r = 0.89, p < 0.001). The technique should have an important role to play in studying the origin of differences which occur between direct and indirect blood pressure measurements.

Measurement of arterial closing pressure

It has been suggested that certain artifacts in blood pressure measurement by auscultation stem from stiffness of the tissues underneath the pressure cuff, resulting in a component of cuff pressure being required to overcome resistance to brachial artery collapse. This paper describes a technique for measuring the pressure required to collapse a segment of the brachial artery which has been isolated from central arterial pressure. This measurement is termed the arterial closing pressure. In a study of eleven elderly subjects, the artery collapsed spontaneously (zero closing pressure) after being isolated from central pressure in seven subjects. The remaining four required external pressures ranging from 4.6 to 10.7 kPa (35 to 81 mmHg) in order to collapse the artery. Thus arterial closing pressure may frequently be a significant fraction of arterial blood pressure in the elderly population, and may contribute to error in the measurement of blood pressure by auscultation. Arterial closing pressure may be a useful tool for investigating the origin of differences between indirect and direct blood pressure measurements, and also in the investigation of spontaneous arterial closure.

The profunda femoris: a durable outflow vessel in aortofemoral surgery

Aorta-common femoral artery bypass is the standard operation for relief of aortoiliac occlusive disease. When extensive superficial femoral artery disease coexists, the profunda femoris, even in its distal portion, may be used as the outflow vessel. To test this assumption we compared cumulative patency, limb salvage, and the need for distal bypass of 134 aorta-profunda femoris and 151 aorta-common femoral artery bypasses performed consecutively for aortoiliac occlusive disease over a 12-year period. We also analyzed results of proximal (n = 103) and distal (n = 31) aortoprofunda bypasses. Angiographic and noninvasive studies showed greater disease in limbs undergoing aorta-profunda femoris bypass. However, no difference was observed in cumulative patency (91% +/- 6% vs 96% +/- 3%) or limb salvage (90% +/- 6% vs 94% +/- 3%) at 5 years. Seventeen distal bypasses in the group undergoing profunda femoris bypass and 20 distal bypasses in the group undergoing common femoral artery bypass were required to maintain limb salvage. Proximal and distal aorta-profunda femoris bypasses showed no difference in cumulative patency (91% +/- 9% vs 95% +/- 6%) or limb salvage (94% in each group) at 3 years. Standard aorta-common femoral artery and aorta-profunda femoris bypass provide cumulative patency and limb salvage exceeding 90% at 5 years; concomitant or subsequent distal bypass was required in 12% or limbs undergoing aorta-profunda femoris bypasses. Both proximal and distal profunda femoris arteries provide a durable outflow tract when aortoiliac and femoropopliteal occlusive disease are combined.

Asymptomatic carotid stenosis: a benign lesion?

Recent reports of the risk of asymptomatic carotid stenosis have been compromised by flawed patient selection or the performance of a large number of carotid endarterectomies during follow-up. We report the natural history of a randomly selected group of asymptomatic patients (n = 188; 114 males and 74 females) with documented carotid artery disease who were prospectively followed without intervention for up to 8 years. Risk factors included ischaemic heart disease in 17%, diabetes in 10%, hypertension in 46% and 88% were smokers. The degree of internal carotid stenosis was classified by duplex scanning and a total of 259 vessels had evidence of atherosclerosis. Study end-points included TIA, CVA and death. At mean follow-up of 4 years 3% of the 96 patients with internal carotid artery stenosis of less than 50% had died and 2% suffered a stroke. Six per cent of patients with a stenosis of 50-79% had died and 4% and 2% had suffered a CVA and TIA, respectively. In the 59 patients with greater than 80% stenosis 7% had suffered a TIA and an additional 7% a CVA, while 2% had died. None of the patients suffering a stroke had an antecedent TIA. Though the incidence of ischaemic events is significantly higher in patients with greater than 80% stenosis the incidence of unheralded stroke remains low. We therefore continue to recommend a conservative approach to the management of asymptomatic carotid stenosis.