J. Collin

OXFORD SCREENING PROGRAMME FOR ABDOMINAL AORTIC ANEURYSM IN MEN AGED 65 TO 74 YEARS

824 men aged 65 to 74 were invited for ultrasound screening of the aorta and 426 (51.7%) attended. An abdominal aortic aneurysm was discovered in 23 (5.4%), and in 10 (2.3%) the aneurysm was 4.0 cm or more in diameter. 2 other patients had a common iliac artery aneurysm. The 36 men who had objective evidence of occlusive arterial disease of the lower limbs were twice as likely to be tobacco smokers and accounted for 5 (20%) of the aneurysms discovered. Extension of this screening programme to England and Wales could be expected to identify 52,500 men with an abdominal aortic aneurysm. If elective surgical replacement of the aneurysm were to be accepted by 60% of those with aneurysms 4 cm or more in diameter, 6000 unnecessary deaths from aortic aneurysm rupture could be prevented.

Is percutaneous transluminal angioplasty better than exercise for claudication?—Preliminary results from a prospective randomised trial

Percutaneous transluminal angioplasty (PTA) is a commonly performed procedure for the treatment of intermittent claudication despite the lack of controlled studies. The aim of this study was to compare PTA with supervised exercise therapy for patients with arterial occlusive disease judged suitable for PTA at angiography. Patients were assessed before treatment commenced and at three monthly intervals afterwards. Assessment included measurement of resting ankle brachial pressure indices (ABPI), and claudicating and maximum walking distances on a treadmill up a 10 degrees incline. Twenty patients were randomised to receive PTA and 16 exercise. The groups were similar in age, sex, smoking habits and arteriographic pattern of disease. In the PTA group two patients had angioplasties that were technically unsuccessful and two other patients subsequently required surgery. One patient in the exercise group subsequently had a PTA. After PTA, mean ABPI were significantly improved at 3, 6 and 9 months (P less than 0.01) without a corresponding significant increase in mean maximum walking distances. However in the exercise group despite no increase in mean ABPI, mean maximum walking distances increased progressively, with significant increases at 6, 9 and 12 months (P less than 0.01).

Exercise training versus angioplasty for stable claudication. Long and medium term results of a prospective, randomised trial

OBJECTIVES To compare percutaneous transluminal angioplasty (PTA) against exercise training in the treatment of stable claudication. DESIGN Prospective, randomised trial. MATERIALS Fifty-six patients with unilateral, stable, lower limb claudication assessed prior to randomisation, at 3 monthly intervals for 15 months, and at approximately 6 years follow-up. Thirty-seven patients were available for long term review. OUTCOME MEASURES Ankle/brachial pressure index (ABPI), treadmill claudication and maximum walking distances, percentage fall in ankle systolic pressure after exercise. RESULTS Significant increases were seen in ABPI in the patients treated with PTA at all assessment to 15 months. However in terms of improved walking performance, the most significant changes in claudication and maximum walking distance were seen in the exercise training group. At long term follow-up, there was no significant difference between the groups. Subgroup analysis by angiographic site of disease showed greater functional improvement in those patients with disease confined to the superficial femoral artery treated by exercise training. The overall prognosis for the whole group of patients was benign, with only two (4%) undergoing amputation. CONCLUSIONS Exercise training confers a greater improvement in claudication and maximum walking distance than PTA, especially in patients with disease confined to the superficial femoral artery.

Randomised controlled trial of laparoscopic versus open repair of inguinal hernia: early results.

Abstract Objective: To establish the safety, short term outcome, and theatre costs of transabdominal laparoscopic repair of inguinal hernia performed as day surgery. Design: Randomised controlled trial. The control operation was the two layer modified Maloney darn. Setting: Teaching hospital and district general hospital. Subjects: 125 men randomised to laparoscopic or open repair of inguinal hernia. Outcome measures: Morbidity, postoperative pain and use of analgesics, quality of life, and theatre costs. Outcome was assessed by questionnaires administered to patients daily for 10 days and at six weeks postoperatively and by outpatient review at six weeks. Return to normal activity was assessed by questionnaire at three months. Results: One vascular complication (2%) occurred in the group that had open repair. Seven complications (12%) including vessel injury and early recurrence arose in the group that had laparoscopic repair (difference in complication rate 10% (95% confidence interval 4% to 18%; P=0.02). Pain scores and quality of life assessed by the short form 36 showed a significant benefit to the group that had laparoscopic repair in the early postoperative period. Return to normal activity was not significantly different between the two groups. Total theatre costs were higher in the group that had laparoscopic repair (mean cost for laparoscopic repair pounds sterling850 (pounds sterling622 to pounds sterling1078); mean cost for open repair pounds sterling268 (pounds sterling245 to pounds sterling292)). Conclusions: Because of the greater complication rate and higher theatre costs forlaparoscopic repair and the patient outcome preferences expressed, the results of larger trials of clinical and cost effectiveness using recurrence as the primary outcome measure should be known before laparoscopic herniorrhaphy is widely adopted.

The efficacy of transfemoral endovascular aneurysm management: A study on size changes of the abdominal aorta during mid-term follow-up

OBJECTIVES The aim of this study was to assess efficacy of transfemoral endovascular aneurysm management (TEAM) during mid-term follow-up. DESIGN Prospective multicentre study. MATERIALS AND METHODS In 26 patients treated by a Tube Endograft, the pre- and postoperative contrast enhanced computed tomography (CT) images were reviewed in a blinded fashion. Aortic diameters were measured at the coeliac trunk, the inferior and superior aneurysm neck and the level of the maximal aneurysm size. The changes in diameter were related to the presence or absence of an endoleak. RESULTS The median follow-up was 12 months. In 10 patients an endoleak was found. Three endoleaks sealed spontaneously within 30 days after operation. All aneurysms with persistent endoleaks expanded, at a median rate of 0.30 mm per month. Four patients were converted between 9 and 14 months after TEAM. Aneurysms excluded by the endoprosthesis showed a median shrinkage of 0.41 mm per month. The inferior aneurysm neck demonstrated significant growth during follow-up, unrelated to endoleaks. CONCLUSIONS This study demonstrated the efficacy of TEAM in discontinuing the process of aneurysm expansion. Complete seal of the aneurysm sac after TEAM leads to shrinkage or arrest of growth of the aneurysm, while persistent endoleak is associated with progressive expansion.

Early experience with transfemoral endovascular aneurysm management (TEAM) in the treatment of aortic aneurysms

OBJECTIVES To evaluate the early experience with transfemoral endovascular aortic aneurysm management using the Endovascular Grafting System. DESIGN Multi-centre prospective evaluation of the implantation procedure and early results (median follow-up 153 days). SETTING Department of Surgery, University Hospital Utrecht, The Netherlands; Department of Surgery, University of Sydney, Australia; University of Leicester School of Medicine, Leicester, U.K., Department of Surgery, Karolinska Hospital, Stockholm, Sweden and Nuffield Department of Surgery, University of Oxford, John Radcliffe Hospital; Oxford, U.K. MATERIALS 31 consecutive patients treated in 13 months. CHIEF OUTCOME MEASUREMENTS: Peri and postoperative morbidity and mortality in accordance with the recommendations of the Ad Hoc Committee on Reporting Standards. MAIN RESULTS Graft placement was initially successful in all 31 patients. In one patient the endograft had to be replaced by a standard aortic tube graft because of extra graft flow in the aneurysm sac, and complaints of back pain. One patient died from multiple organ failure, 11 days after the operation. In three patients five severe adverse events were recorded. Breaks of the attachment system were encountered in two patients. These failures did not have severe clinical consequences for individual patients. CONCLUSIONS Transfemoral Endovascular Aneurysm Management is a technically demanding procedure that requires special training in both catheter and surgical techniques. The potential for less operative morbidity when compared to conventional surgery and the prospect of technical improvements in graft and introduction system design will make TEAM an important tool in aneurysm management in the near future.

Prospective evaluation of quality of life after conventional abdominal aortic aneurysm surgery

OBJECTIVES To evaluate the changes in quality of life following conventional abdominal aortic aneurysm repair. DESIGN Prospective study. MATERIALS AND METHODS Fifty-nine consecutive patients (50 men; nine women) in two surgical centres were investigated preoperatively, and at 6 weeks, 3 months and 6 months postoperatively. Quality of life was measured using the Short Form 36 (SF 36) questionnaire and the York Quality of Life questionnaire, from which the Rosser index was calculated. RESULTS Rosser index assessment showed restoration of quality of life to preoperative levels by 3 months, and significant improvement at 6 months. Changes in the SF 36 revealed significant improvement in mental health, and physical role limitation at all times postoperatively. Social function worsened at 6 weeks but improved to preoperative levels by 3 and 6 months after surgery. CONCLUSIONS Quality of life was improved after open aortic aneurysm repair. The time course of recovery shows a predominant improvement between 6 weeks and 3 months postoperatively.

Growth rates of subclinical abdominal aortic aneurysms—implications for review and rescreening programmes

One hundred and six patients with abdominal aortic aneurysms (AAAs) of 2.5 to 3.9 cm in anteroposterior diameter were reexamined by ultrasound every 6 months for up to 3 years after diagnosis. Annual growth rates were 0.11 cm +/- 0.03 (mean +/- SE) for AAAs 2.5 to 2.9 cm and 0.29 cm +/- 0.08 for AAAs 3.5 to 3.9 cm (P = 0.002). In 73 patients (69%) the annual rate of increase in diameter was 0.2 cm or less and only 12 aneurysms (11%) grew at more than 0.5 cm per annum. We conclude that: (1) for AAAs less than 4.0 cm diameter remeasurement more often than every 6 months is unnecessary; (2) interval screening (rescreening) for AAAs more frequently than 5 yearly is unlikely to detect sufficient clinically significant aneurysms to be worthwhile.

How fast do very small abdominal aortic aneurysms grow

Fifty patients with abdominal aortic aneurysms from 2.5 to 5.0 cm in anteroposterior diameter (median 3.1 cm, mean +/- S.E. 3.3 +/- 0.1 cm) were initially offered non-operative treatment. Two patients have subsequently undergone successful elective aneurysm resection because of increase in aneurysm size, and a third has died. The median annual growth rate of the aneurysm has been 0.22 cm and 77.8% increased in size between 6 monthly ultrasound examination. For aneurysms less than 4.0 cm the maximum 6 monthly increment in diameter was 0.7 cm. Even the smallest abdominal aortic aneurysms usually progressively increase in size and 6 monthly ultrasound remeasurement of aneurysm diameter is an essential component of non-operative management.

The role of sympathectomy in current surgical practice

Historically sympathectomy has been employed in the treatment of a variety of disparate disorders but in most there is little if any objective clinical evidence of its efficacy. Review of the literature confirms that sympathectomy provides an effective and permanent cure for hyperhidrosis of the hands and feet, and at present palmar hyperhidrosis is the major indication for its regular use. Sympathetic denervation of the hands is currently most easily achieved with minimal morbidity by thoracoscopic ablation of the second thoracic ganglion. Some evidence testifies to the efficacy of sympathectomy in the rare patients with true major causalgia. Clinical experience suggests that Raynauds phenomenon in the feet can be usefully ameliorated by sympathectomy but in the hands any benefit is short lived and there is no effect on the prognosis of the disease. A weak case can be made for sympathectomy for ischaemic rest pain when arterial surgery is impractical but there is no reliable evidence to support its use in Buergers disease, intermittent claudication, diabetic vascular disease or ischaemic ulceration or gangrene.