D. J. A. Scott

The effect of diabetes mellitus on the outcome of angioplasty for lower limb ischaemia

Angioplasty is an important tool in the armamentarium of the clinician dealing with atherosclerotic disease. Diabetic patients with occlusive disease pose special problems. Four hundred and twenty‐five lesions were dilated in 370 patients. No difference in site was found when comparing the diabetic and non‐diabetic groups (p < 0.001), but a significant difference in indication for treatment was observed. Cumulative patency at 5 years for iliac lesions in non‐diabetic patients was 61.2% and in diabetic patients was 35.6% (p < 0.05), for superficial femoral and popliteal artery lesions in non‐diabetic patients it was 49.7% and in diabetic patients it was 38.8% (NS). The need for subsequent surgical intervention (p < 0.01) and risk of death (p < 0.001) are both significantly greater in the diabetic group. This study shows that angioplasty is a technique that can be used with success in diabetic patients and if the indications for intervention are compared, diabetic patients do no worse.

Preoperative assessment of the pedal arch using pulse generated runoff and subsequent femorodistal outcome

Calf vessel continuity with an intact pedal arch is an important factor in femorodistal (FD) bypass for critical ischaemia. Pulse generated runoff (PGR) was used in combination with the pedal arch patency test of Roedersheimer to determine preoperatively calf vessel and pedal arch patency. Three pedal arch groups were identified; complete (two calf vessels in continuity), incomplete (one vessel) and occluded (no vessels). One hundred non-reversed FD grafts were performed for critical ischaemia (63 men and 37 women), median age 72 (range 43-89 years). Sixteen grafts were to the above knee popliteal artery, 36 to the distal popliteal, three to the tibioperoneal trunk and 45 to a single calf vessel. There were 25 complete, 64 incomplete and 11 occluded pedal arches. The overall primary patency rate was 73%, nine grafts were successfully revised giving a secondary patency rate of 83.5%. The secondary graft patency rates for the above knee popliteal, below knee popliteal, tibioperoneal and single calf vessel grafts were 100, 92, 66 and 66% respectively. The 1 year graft patency rates for grafts to a complete, incomplete and occluded pedal arch were 88, 75 and 9% respectively (Lee-Desu p < 0.01). Similar results were obtained for limb salvage; 100, 84 and 24% respectively (p < 0.01). These results confirm the value of PGR in the preoperative assessment of patients with critical ischaemia. In reconstructions to the popliteal artery, PGR derived pedal arch status does not appear to influence the outcome. By contrast PGR derived pedal arch status in an excellent predictor of success following reconstructions to a single calf vessel.(ABSTRACT TRUNCATED AT 250 WORDS)

Choice of agent for peripheral thrombolysis

Evidence has been accumulating that tissue plasminogen activator (tPA) is a more rapid and effective agent than streptokinase for peripheral thrombolysis. Twenty‐three patients with acute limb‐threatening ischaemia treated with tPA (0.5 mg h−1) over 15 months were compared with 20 consecutive patients previously receiving streptokinase (5000–10000 units h−1). There were no major differences between the rates of complete and partial lysis (61 per cent for tPA versus 65 per cent for streptokinase) or limb salvage (65 versus 55 per cent respectively). Complication rates were also similar. It was not possible to show that tPA, an agent ten times more expensive than streptokinase, was superior for peripheral thrombolysis.

Failure of peripheral arterial balloon angioplasty: does platelet deposition play a role?

The pathophysiological response to peripheral percutaneous transluminal balloon angioplasty in 20 patients was investigated using 111-Indium labelled platelets. Platelet deposition was quantified by measuring the degree of radioactivity uptake at angioplasty and control sites using a computer linked system and expressing the uptake as a ratio of angioplasty/control. Following platelet labelling, scans were performed before angioplasty and at 1, 24 and 48 h after angioplasty. To assess patency of the angioplasty, ankle brachial Doppler pressure indices were performed and supported by repeat angiograms if doubt of patency existed. All patients were followed-up at 1 week, 1 month and 6 months to correlate the degree of early platelet uptake with failure. The mean +/- sem platelet radioactivity ratio at the angioplasty site increased from 1.1 +/- 0.1 prior to the procedure to a peak of 2.1 +/- 0.3 at 1 h (p less than 0.01), 1.6 +/- 0.2 at 24 h (p less than 0.05), and 1.7 +/- 0.3 at 48 h (p less than 0.05). Angioplasties that failed within 6 months tended to have a higher maximum early platelet uptake (3.1 +/- 0.6) compared to successful angioplasties (1.9 +/- 0.3) but the difference was not significant in the numbers studied. This study provides a suitable model to assess the role of platelet accumulation in angioplasty failure and the influence of various antiplatelet regimes.

Spontaneous rupture of suprarenal aneurysms: a late sequel to infrarenal aortic aneurysms repair.

The development of a false aneurysm occurring at the anastomotic suture line is a rare late complication following abdominal aneurysm repair. 1 The development of true suprarenal aneurysms following repair of infrarenal aneurysm is extremely rare and is probably due to progression of degenerative atherosclerosis. We report two cases of rupture of a suprarenal aortic aneurysm which have developed since the repair of an infrarenal aortic aneurysm.