James Rh Scurr

Fenestrated endovascular repair for juxtarenal aortic aneurysm.

The outcome of fenestrated endovascular aneurysm repair (F‐EVAR) was evaluated.

Wholly endovascular repair of thoracoabdominal aneurysm.

The aim was to evaluate a wholly endovascular approach to the repair of thoracoabdominal aortic aneurysm (TAAA).

Medicolegal claims following laparoscopic cholecystectomy in the UK and Ireland

INTRODUCTION The causes and outcomes of medicolegal claims following laparoscopic cholecystectomy were evaluated. SUBJECTS AND METHODS A retrospective analysis of the experience of a consultant surgeon acting as an expert witness within the UK and Ireland (1990-2007). RESULTS A total of 151 claims were referred for an opinion. Sixty-three related to bile duct injuries and four followed major vascular injury. Bowel injury resulted in 17 claims. A postoperative biliary leak not associated with a bile duct injury was responsible for 25 claims. Other reasons for claims included spilled gallstones, port-site herniae, haemorrhage and other recognised complications associated with laparoscopic cholecystectomy. Twelve of the claims are on-going, two went to trial, 79 (52%) were settled out of court and 58 (38%) were discontinued after the claimants were advised that they were unlikely to win their case. Disclosed settlement amounts are reported. CONCLUSIONS Bile duct and major vascular injuries are almost indefensible. The delay in diagnosis and (mis)management of other recognised complications following laparoscopic cholecystectomy have also led to a significant number of successful medicolegal claims.

Fenestrated Aortic Stent Grafts

Fenestrated stent grafts have been developed to offer an endovascular treatment option to those patients with abdominal aortic aneurysms whose infrarenal necks are anatomically unsuitable for endovascular repair with standard infrarenal devices. The ability to have customized fenestrations that will preserve flow to essential visceral arteries allows proximal seal and fixation to be achieved at and above the renal level. This article discusses patient selection, stent-graft design, and the importance of accurate planning. Deployment techniques along with complications and their avoidance are considered. The published midterm results are reviewed and appear to justify the continued use and evaluation of this technique as an alternative to open surgical repair in high-risk patients with infrarenal necks unsuitable for standard endovascular repair.

Fenestrated stent-graft repair: which stent should be used to secure target vessel fenestrations?

Purpose: To investigate in an in vitro model the ability of different covered and uncovered stents to resist displacement/migration of a fenestrated stent-graft. Methods: Three different types (2 covered, 1 bare) of commonly used 7-mm balloon-expandable stainless steel stents (Jostent, Advanta V12, and Palmaz Genesis) were investigated in a testing rig consisting of 2 overlapping tubes with 2 sets of 7-mm holes representing bilateral renal artery fenestrations and ostia. The rig was attached to a tensile tester via pneumatic clamps. The stents were deployed without flaring to 7 mm through the overlapping holes. The rig was moved apart at a constant rate of 12 mm/min up to a maximum displacement of 6 mm; force versus displacement values were recorded while stent deformation was observed. Tests were repeated at least 6 times for each stent type at room temperature. The median force required to cause a 25%, 50%, or 75% reduction in cross-sectional area of the bilateral “renal artery” stents was determined. Results: The median force (interquartile range) required to cause a 50% reduction in cross-sectional area of identical bilateral “renal artery” stents securing fenestrations was 25.1 N (8.1) for a covered Jostent, 9.3 N (0.9) for a covered Advanta V12 stent, and 7.5 N (0.7) for a bare Palmaz Genesis stent. The differences were statistically significant (p<0.01) between stents at each of the 3 levels of cross-sectional area reduction. Conclusion: There is a significant difference in the ability of different commercial “non-dedicated” stents to withstand a crushing force when deployed within endograft fenestrations, which has important implications for clinical practice.

EVAR in Iliac Occlusion

Purpose: To report the recanalization of an occluded common iliac artery (CIA) to allow endovascular repair of an abdominal aortic aneurysm (AAA) with a bifurcated stent-graft. Case Report: A 76-year-old man with a 75-mm infrarenal AAA and an occluded right CIA was successfully treated with a Zenith bifurcated stent-graft. The right CIA was recanalized allowing access, delivery, and deployment of the stent-graft. Follow-up computed tomography at 9 months showed no evidence of endoleak; maximum aneurysm diameter was reduced to 72 mm, and the iliac vessels were patent. Conclusion: Bifurcated stent-graft repair of an AAA can be performed following recanalization of an occluded CIA. This option may be preferable to an open repair or an aortomonoiliac stent-graft with extra-anatomical bypass in some patients. Long-term surveillance will be necessary to ensure freedom from iliac-related secondary intervention.

Long-term follow-up of fenestrated endovascular repair for juxtarenal aortic aneurysm

Fenestrated endovascular aneurysm repair (FEVAR) is increasingly being used for juxtarenal aortic aneurysms. The aim of this study was to review long‐term results and assess the importance of changing stent‐graft design on outcomes.

www.Accurate information for varicose vein patients.com

INTRODUCTION The aim of this study was to review the information available to the public regarding the treatment of varicose veins on dedicated UK-based websites. PATIENTS AND METHODS Websites were identified by using the Google search engine. All identified websites were examined, noting the range of treatments explained and their stated potential complications. Website ownership was also recorded. RESULTS A total of 49 websites were identified, belonging to individual physicians (21), private clinics or groups (15), national institutions (4) and device/drug manufacturers (4). Five websites were simply redirecting portals and, hence, were excluded from further analysis. Treatment methods discussed were conventional surgery (32), endovenous laser [EVLA] and/or radiofrequency ablation [RFA] (31), and ultrasound-guided foam sclerotherapy [UGFS] (27). Only 19 websites (43%) discussed all treatment methods. Complications mentioned following surgery were: cutaneous nerve damage (56%), recurrence (56%), infection (53%), bleeding (41%) and venous thrombo-embolism (38%). Complications following EVLA/RFA were: cutaneous nerve damage (42%), recurrence (42%), venous thrombo-embolism (39%) and burns (35%). Complications following UGFS were: pigmentation (59%), venous thrombo-embolism (48%), ulceration (41%), recurrence (41%), allergy (26%) and visual disturbance (26%). CONCLUSIONS Over 50% of the websites examined did not mention all the management methods now available for varicose veins. More importantly, the majority of the websites did not warn of the common complications of intervention. Currently, information on the Internet cannot be relied upon to supplement informed consent and may actually generate unrealistic patient expectations.

Causes of successful medico-legal claims following amputation

Introduction The causes of successful medico-legal claims following amputation were reviewed. Methods A retrospective analysis of claims handled by the National Health Service Litigation Authority, from 2005 to August 2010, was performed. Under the Freedom of Information Act, the National Health Service Litigation Authority provided limited details on closed claims, settled with damages, following a search of their database with the term “amputation.” No demographic data were provided. Results During this period, 174 claims were settled by the National Health Service Litigation Authority, who paid out more than £36.3 million. The causes of the claims were the need for a lower limb amputation due to a delay in the diagnosis and or treatment of arterial ischaemia (56), an iatrogenic injury (15), the development of preventable pressure sores (15), the delay and or failure to diagnose a limb malignancy (6) and the delay in the management of an infected pseudo-aneurysm (1). Complications following orthopaedic surgery resulted in 25 successful claims as did the delayed diagnosis or mismanagement of 10 lower limb fractures. Additional claims followed the amputation of the wrong toe (1), a retained foreign body (2), an unnecessary amputation (4), inadequate consent (4), failure to provide thrombo-prophylaxis following amputation resulting in death (2) and a diathermy burn injury during an amputation (1). Delay in the diagnosis of and/or failure to manage an injury or infection resulted in 21 upper limb amputations. There was insufficient information provided in the remaining 11 claims to determine how the claim related to an amputation procedure. The largest single payout for damages (£1.9 million) resulted from the failure to diagnose and treat a femoral artery injury following a road traffic accident leading to an eventual below knee amputation. Conclusion Delays in the diagnosis and or treatment of arterial ischaemia were the commonest reasons for a settled claim. Lessons can be learnt from potentially preventable cases that can be incorporated in medical education and training programs with the aim of reducing both amputation rates and litigation costs.

Traveller's thrombosis: airlines still not giving passengers the WRIGHT advice!

Introduction This study has examined the impact of the World Health Organizations Research into Global Hazards of Travel (WRIGHT) Projects phase 1 report on the information given by airlines to their passengers regarding travellers thrombosis. Methods Official websites of all airlines flying from Heathrow (UK) and John F Kennedy (USA) were located through links on the websites of these two busy international airports. In June 2007, each site was scrutinized by three independent researchers to identify if travellers thrombosis and its risk factors were discussed and what methods of prevention were advised. This exercise was repeated a year after the publication of the WRIGHT report. Results One hundred and nineteen international airlines were listed in 2007 (12 were excluded from analysis). A quarter (27/107) of airlines warned of the risk of travellers thrombosis. A year later, five airlines were no longer operational and there had been no increase in the discussion of travellers thrombosis (23/102). Additional risk factors discussed in June 2007 versus September 2008: previous venous thromboembolism (16%, 15%); thrombophilia (14%, 15%); family history (11%, 9%); malignancy (12%, 14%); recent surgery (19%, 16%); pregnancy (17%, 16%) and obesity (11%, 12%). Prophylaxis advice given in June 2007 versus September 2008: in-flight exercise (34%, 42%); Hydration (30%, 34%); medical consultation prior to flying (20%, 18%); graduated compression stockings (13%, 12%); aspirin (<1%, <1%) and heparin (5%, 7%). Conclusions The majority of world airlines continue to fail to warn of the risk of travellers thrombosis or offer appropriate advice. Alerting passengers at risk gives them an opportunity to seek medical advice before flying.