Ma Bailey

Modeling the Growth of Infrarenal Abdominal Aortic Aneurysms.

BACKGROUNDnAbdominal aortic aneurysm (AAA) growth is a complex process that is incompletely understood. Significant heterogeneity in growth trajectories between patients has led to difficulties in accurately modeling aneurysm growth across cohorts of patients. We set out to compare four models of aneurysm growth commonly used in the literature and confirm which best fits the patient data of our AAA cohort.nnnMETHODSnPatients with AAA were included in the study if they had two or more abdominal ultrasound scans greater than 3 months apart. Patients were censored from analysis once their AAA exceeded 5.5 cm. Four models were applied using the R environment for statistical computing. Growth estimates and goodness of fit (using the Akaike Information Criterion, AIC) were compared, with p-values based on likelihood ratio testing.nnnRESULTSnOf 510 enrolled patients, 264 met the inclusion criteria, yielding a total of 1861 imaging studies during 932 cumulative years of surveillance. Overall, growth rates were: (1) 0.35 (0.31,0.39) cm/yr in the growth/time calculation, (2) 0.056 (0.042,0.068) cm/yr in the linear regression model, (3) 0.19 (0.17,0.21) cm/yr in the linear multilevel model, and (4) 0.21 (0.18,0.24) cm/yr in the quadratic multilevel model at time 0, slowing to 0.15 (0.12,0.17) cm/yr at 10 years. AIC was lowest in the quadratic multilevel model (1508) compared to other models (P < 0.0001).nnnCONCLUSIONnAAA growth was heterogeneous between patients; the nested nature of the data is most appropriately modeled by multilevel modeling techniques.

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.

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

NHS Choices Underreports the Workload of High Volume Centres for Carotid Endarterectomy and Abdominal Aortic Aneurysm Repair

In the 2010 white paper Equity and Excellence: Liberating the NHS, the government calls for a service focused on shared decision making between doctors and their patients.1 ‘No decision about me, without me’ was one of the key messages. Furthermore, the annual National Health Service (NHS) patient survey reveals a sustained but unmet demand for greater patient involvement in treatment decisions.2 The white paper calls for an information revolution in the NHS in order to place valid information in the hands of patients, enabling valid choices to be made.1 This process requires both accurate data and suitable dissemination to patients.

Spontaneous aortic dissection within an infrarenal AAA

Aortic dissection occurring in the infrarenal abdominal aorta is uncommon. We present the case of a patient presenting with an enlarging abdominal aortic aneurysm and concurrent dissection (with associated radiological imaging) and briefly discuss the literature relating to this phenomenon.

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.