D.J.A. Scott

Endovascular stent-grafts for superficial femoral artery disease: results of 1-year follow-up.

PURPOSEnTo document a preliminary study to assess the deployment and outcomes of endoluminal stent grafting in the superficial femoral artery (SFA) with use of a prototype device.nnnMATERIALS AND METHODSnTwenty patients with lifestyle-limiting intermittent claudication were selected for treatment with a balloon-mounted expansive polytetrafluoroethylene graft. All patients had angiographically proven SFA disease (median length, 17 cm) with normal arterial inflow and at least two calf vessels patent to the ankle. Follow-up was by means of ankle brachial pressure index (ABPI), duplex ultrasound, and angiography.nnnRESULTSnFourteen patients were successfully treated. Six patients were excluded: five by the study protocol and one because the procedure was a technical failure. ABPI rose from 0.6 before treatment to 1.0. The treated limbs became asymptomatic. Twelve-month primary, primary assisted, and secondary patency rates of treated patients were 29%, 50%, and 64%.nnnCONCLUSIONnEndovascular stent grafting of SFA lesions is technically feasible, but the patency rates obtained with this design are inferior to those obtained with conventional surgical bypass.

Outcome following saphenopopliteal surgery: a prospective observational study

Objectives High recurrence rates following small saphenous varicose vein surgery have been reported. The aim of this study was to ascertain initial success rates following saphenopopliteal junction (SPJ) surgery using pre- and postoperative duplex scanning. Methods A prospective study was performed on patients with ultrasound-proven SPJ reflux. Patients underwent preoperative duplex skin marking and a postoperative quality assurance scan. Results Ninety procedures were performed in 88 patients. The SPJ was successfully ligated in 87 (96.7%) cases. Reflux was completely abolished in 51 (56.7%) cases, but persisted solely in the small saphenous vein (SSV) in 32.2%. Subsequently, 10 consecutive patients underwent 11 SPJ ligations with stripping of the SSV. Follow-up ultrasound scan demonstrated successful ligation of the SPJ and elimination of superficial venous reflux. Conclusion This study demonstrates that preoperative duplex SPJ marking results in a high percentage of successful ligation. Given that residual persistent reflux was avoided in patients who underwent stripping of the SSV, we propose that patients who require SPJ surgery undergo duplex marking along with specific consideration with regard to treatment of the residual SSV.

Primary care trust commissioning of varicose vein intervention – New guidance needed?:

Objectives In light of evidence of national variability in service commissioning of varicose vein intervention, our aim was to evaluate the current state of primary care trust commissioning for all forms of varicose vein intervention in England. We also sought to clarify the extent to which access to endovenous and surgical varicose vein services is being restricted. Methods Under the Freedom of Information Act (2001), a structured email survey was sent to 108 primary care trusts in England. Trusts were asked how many elective endovenous laser therapy and open procedures were commissioned from 2008 to 2011 and they were asked to submit their commissioning policy for analysis. The ‘qualifying criteria’ expressed in each policy were analysed by theme and geographical region. Results Of 108 surveys, 95 (88%) were completed and returned. Of these, 91 (96%) stated that varicose vein interventions were actively commissioned. Eighty-eight (97%) of primary care trusts that commissioned varicose vein interventions stated that access was restricted. Qualifying criteria varied considerably between regions. Conclusions Access to varicose vein intervention appears to be restricted, with national variation in commissioning across England. This might have an impact on patient care and surgical training. We propose that a national decision be made about which varicose vein patients should be offered funding for treatment on the National Health Service.

Early re-presentations and the potential role of catheter-directed thrombolysis in patients diagnosed with a lower limb deep vein thrombosis: a single-centre experience.

Introduction Catheter-directed thrombolysis (CDT) for iliofemoral deep vein thrombosis (DVT) restores venous patency, reduces the risk of the post-thrombotic syndrome and may reduce longer term treatment costs. This study assessed the potential role of CDT in patients with DVT with regard to representation following the index event. Methods A retrospective review of all patients with a positive lower limb DVT scan. Potential suitability of each patient to undergo CDT was based on well-recognized inclusion/exclusion criteria. Results In total, 1689 patients underwent a DVT-specific lower limb venous duplex. A total of 269 were found to have a DVT. Fifty-three of these patients met the inclusion criteria for CDT (only 2 underwent CDT). Fifty-nine of the 269 patients with an index DVT re-presented to our institution with a venous thromboembolism-related clinical event. These patients were significantly younger than those who did not reattend. A higher proportion of patients who represented were deemed suitable for CDT for the index DVT compared with those who did not represent (17/59 versus 36/210; P = 0.04). Conclusion This pragmatic study highlights the fact that significant number of patients return to secondary care with actual/perceived complications following initial diagnosis and treatment of a DVT which may have been amenable to CDT.

A Pilot Study Comparing the Use of Below-Knee and Above-Knee Graduated Stockings in Patients with Superficial Venous Incompetence

Objective: Investigation of the effects of high- and low-ankle-pressure, above- and below-knee compression stockings on the haemodynamics of normal and superficially incompetent venous systems. Design: Prospective duplex study of a normal group and a venous incompetence group randomised to high- or low-pressure stockings. Setting: Vascular services of a University Hospital. Subjects: Six subjects with normal venous haemodynamics (12 limbs) and 12 patients with superficial venous incompetence (20 limbs). Methods: Subjects wore below-knee and then above-knee stockings for 1 week each. Duplex scans were performed at the outset and end of the study and on fitting and after wearing each stocking type. Main outcome measures: Duplex-derived femoral and popliteal venous velocities were measured and indexed against the initial velocity. Results: Below-knee stockings produced only minor changes. Above-knee stockings produced increased velocities in normal subjects. Similar changes were only seen with higher-pressure stockings in patients with incompetence. Conclusion: Above-knee, high-ankle-pressure stockings produce increased deep venous flow velocities.

Compression of the dorsalis pedis artery: a novel cause of blue toe syndrome.

Blue toe syndrome (BTS) is an important vascular condition characterized by painful blue discoloration of one or more digits. It is frequently due to emboli and is important because of the risk of progressive ischemia and tissue loss. A 53-year-old male presented with recurrent episodes of painful blue discoloration and blistering of the skin of the right hallux. On examination, the patient was found to have a cool, blue-purple great toe; all peripheral pulses were present. The patient was investigated for coagulopathy and potential sources of emboli, but the only abnormality was significant stenosis of the dorsalis pedis artery due to extrinsic compression by the extensor hallucis brevis tendon. In the absence of any other embolic source or abnormality, we believe that this case presents a novel and potentially remediable cause of BTS and indicates the need for a careful search for an underlying lesion when common causes of BTS have been excluded.

Systematic review and meta-analysis of the effects of statin therapy on abdominal aortic aneurysms (Br J Surg 2011; 98: 362–353)

Sir The use of on-table cholangiography (OTC) during laparoscopic cholecystectomy remains a contentious issue, and the authors are to be congratulated on completing a randomized controlled trial to further this debate. However, we suggest that the results of their trial can equally be interpreted in support of OTC. The 3–4 per cent incidence of choledocholithiasis is similar between groups when including patients readmitted with ‘passed stones’. The trial supports the use of OTC in reducing readmissions, although it is underpowered for this to achieve significance. Although not all patients with choledocholithiasis become symptomatic, what risk of jaundice, acute pancreatitis or cholangitis is acceptable before discounting the benefits of OTC? OTC is demonstrated in this trial to be quick, with no added morbidity, and the authors acknowledge the importance of OTC in delineating biliary anatomy. Indeed, for this reason OTC was performed in nine patients in the cholecystectomy-alone group, with a resultant change in management in three patients. In a fourth patient they question whether OTC may have prevented bile duct injury. Studies have demonstrated a reduction in the incidence of bile duct injuries with routine use of OTC1 and, until an adequately powered study addresses readmission rates and risk of complications from choledocholithiasis, surely OTC remains justified? As a final observation, transcystic cholangiography allows ‘milking’ of the duct to clear any cystic duct debris or stones, a common finding in our experience. Was this the authors’ experience, and should these be included as ‘positive’ OTCs? Although difficult to prove any therapeutic benefit of removal of cystic duct debris, it is often the likely cause of symptoms and cystic duct clearance may reduce the risk of passage of debris into the common bile duct. A. J. Cockbain, A. L. Young and G. J. Toogood Department of Hepatobiliary Surgery, St James’ University Hospital, Leeds, UK (e-mail: a.j.cockbain@leeds.ac.uk) DOI: 10.1002/bjs.7510

Ovarian Mass Causing Paradoxical MI and Leg Ischaemia

Paradoxical embolus through a patent foramen ovale is a well-reported phenomenon. Clinical consequences include stroke, intestinal infarction, lower limb ischaemia, and even acute myocardial infarction (MI), via embolisation to the coronary arteries. We present a case of acute MI, cardiogenic shock, and cardiac arrest caused not by this mechanism, but by embolisation of thrombotic material to the aortic root with transient complete occlusion of the left main stem (LMS) coronary artery. During percutaneous coronary intervention to treat this occlusion the thrombus became lodged at the aortic bifurcation causing lower limb ischaemia. Despite successful treatment of this via bilateral groin exploration and thromboembolectomy the patient became increasingly acidotic and an abdominal and pelvic CT scan was performed. This revealed the source of the thrombus to be the patients congested and compressed pelvic veins which were the result of a large, previously undiagnosed ovarian malignancy with metastatic spread. Although very unusual we feel this case highlights an important differential in the diagnosis of anterolateral MI and images similar to those presented here are previously unreported in the literature.

Implications of serum cholesterol measurement for the vascular surgeon

Objective: To measure the serum total cholesterol in new patients with intermittent claudication and to assess the proportion with ischemic heart disease and untreated hypercholesterolemia. Design: A prospective study with patient history corroborated by a general practitioner telephone questionnaire. Setting: A vascular surgical center in a major teaching hospital. Subjects: Seventy-six consecutive claudicants were studied (median age, 66; range, 46 to 94; 45 men and 31 women), of whom 41 (54%) had ischemic heart disease. Results: The median serum total cholesterol concentration was 6.35 mmol/L (IQR, 5.60 to 7.05 mmol/L). Forty-nine (65%) patients had never had their serum cholesterol assayed before this study despite 24 of them having ischemic heart disease. Conclusions: Previously undiagnosed hypercholesterolemia is commonly revealed in the vascular surgical assessment of patients with intermittent claudication. The cardiac morbidity and mortality of these patients is high and surgeons should therefore be proactive in the instigation of cholesterol-lowering therapy.