R.B. Galland

Management of asymptomatic popliteal aneurysms: the use of a Markov decision tree to determine the criteria for a conservative approach.

With recent improvements in the results of treatment of popliteal aneurysms, it has been suggested that it may be preferable to treat asymptomatic aneurysms conservatively and to operate only if symptoms develop. This hypothesis has been tested using decision analysis, with sensitivity and threshold analysis to establish the conditions under which such a policy would be appropriate. A Markov decision tree has been used to model the problem and the relevant probabilities have been obtained from a review of the current literature. A computer spreadsheet was used to calculate the results of policies of immediate operation or operation only if symptoms occur. Sensitivity and threshold analysis have been carried out to assess the effect of inaccuracy or alteration in the key variables and to determine the optimum policy under different conditions. The results suggest that early elective operation produces better results than conservative management at 1-2 years after presentation. Sensitivity analysis reveals that the most crucial data are the rate of development of symptoms in patients with asymptomatic aneurysms and the expected limb loss and mortality of treatment for symptomatic aneurysms. Threshold analysis has been used to define the values of these parameters that would be necessary for conservative management to be preferred. It is concluded that, based upon the currently available data, the optimum policy is elective treatment of asymptomatic aneurysms.(ABSTRACT TRUNCATED AT 250 WORDS)

Quality of life following percutaneous transluminal angioplasty for claudication

OBJECTIVE To determine quality of life in claudicants before and after percutaneous transluminal angioplasty (PTA). DESIGN Prospective study using EuroQuol questionnaire and visual analogue scales. SETTING District general hospital. MATERIAL Twenty-nine patients undergoing successful PTA. RESULTS Before PTA patients showed a significantly lower EuroQuol score compared with the normal population. There was also marked impairment of patients usual activities, mobility and perceived health state. Following successful PTA the EuroQuol score, perceived health state, mobility, usual activities, pain and discomfort and mental state were all significantly improved. CONCLUSIONS Intermittent claudication impairs quality of life. Following successful PTA there is significant improvement in symptoms and in general health.

Popliteal aneurysms: from John Hunter to the 21st century.

Popliteal aneurysms are rare and tend to occur in older men with significant co-morbidity. Historically, management of popliteal aneurysms can be considered in three broad groups: (i) the technique of Antyllus; (ii) techniques relying upon a collateral circulation; and (iii) techniques involving maintenance or restoration of circulation. Bypass and exclusion is currently been challenged by endovascular techniques which show promise in selected cases. Current controversies in popliteal aneurysms management are: when to repair asymptomatic aneurysms, what operation to do and how to manage acute thrombosis. These have been addressed by studying, prospectively, 73 patients presenting with 116 popliteal aneurysms. Diameter greater than 2 cm is often stated as being an indication for elective operation in asymptomatic popliteal aneurysms. However, distortion of the aneurysm appears to be at least as important as size in determining whether symptoms are likely to develop. Of 17 popliteal aneurysms followed for a median of 34 months with a diameter 2-3 cm and distortion less than 45 degrees , none thrombosed. This is no worse than patency following elective bypass (P = 0.064). Popliteal aneurysms greater than 3 cm in diameter in patients who are unfit or who declined an operation were significantly more likely to develop thrombosis or any other symptom (P = 0.01 and P = 0.004, respectively). Popliteal aneurysms less than 3 cm in diameter with distortion less than 45 degrees can safely be managed by ultrasound surveillance. Popliteal aneurysms with greater diameter or distortion are best operated upon. Bypass, combined with proximal and distal ligation of the aneurysm, resulted in 5-year graft patency of 78% and 65% for popliteal aneurysms originally patent or thrombosed, respectively, with good long-term exclusion of the aneurysm. In addition to the general complications of intra-arterial thrombolysis, acute deterioration of the limb during lysis appears to be a particular problem when dealing with thrombosed popliteal aneurysms. It occurs in about 13% of cases which compares with 2% when dealing with thrombosed grafts or native arteries. Intra-arterial thrombolysis for thrombosed popliteal aneurysms is associated with unacceptably high numbers of complications and thrombolysis should be reserved for intra-operative use only.

Cumulative risk of bypass, amputation or death following percutaneous transluminal angioplasty

OBJECTIVE To define cumulative risk of reconstruction, amputation or death following percutaneous transluminal angioplasty (PTA). DESIGN Non-randomised observational study. PATIENTS AND METHODS Two hundred and thirty-four PTAs in 212 patients. Minimum follow-up 6 months. Examination of data collected prospectively on manual card index. Examination of radiology and theatre ledgers over 2.5-year period. District Information System (Dis Data). Life-table analysis. RESULTS The cumulative risks of reconstruction at 12 months were 14.9% and 6.7%, respectively, following angioplasties below and above the inguinal ligament. Major and minor amputations were more common if the original lesions were below the inguinal ligament (relative risk (RR) 3.32, confidence interval (CI) CI 0.42-26.26 and RR 4.24, CI 0.055-32.9, respectively). They were also more likely in diabetic compared with non-diabetic patients (RR 9.95, CI 2.85-34.47 and RR 3.66, CI 1.28-10.44, respectively). No patient who presented with claudication underwent amputation. Death was more common in patients originally presenting with rest pain or gangrene than claudication (RR 3.94, CI 1.51-10.31). CONCLUSION This study confirms the poor outlook of diabetic patients with peripheral vascular disease or those presenting with rest pain, ulceration or gangrene. Percutaneous transluminal angioplasty was associated with approximately 80% limb salvage rate in those patients during the duration of the study.

Outcome following bypass, and proximal and distal ligation of popliteal aneurysms

The aim of this study was to describe early and late results of proximal and distal ligation for popliteal aneurysm (PA), combined with bypass, with particular reference to the fate of the excluded aneurysm.

Limitations to the Widespread Usage of Low-dose Intra-arterial Thrombolysis

Despite encouraging results, intra-arterial thrombolysis (IAT) has not been readily accepted by British surgeons. In an attempt to clarify the reasons for this we sent a postal questionnaire to surgeons with a vascular interest, asking them to define their present attitude towards IAT. Subsequently, we re-analysed our own clinical data in the light of the answers received. In all 134 surgeons (58%) replied to the questionnaire; 48 (38%) never used IAT and 56 (45%) used it only occasionally. When stated, the main reasons for this limited use were the doubts about efficacy (45%) and lack of radiological support (47%). From November 1988 to August 1990 we used IAT for 82 occlusions (streptokinase 74, rt-PA8). Lysis was achieved in 82% of cases when treatment was started within 1 week of symptoms starting, and 62% with symptoms of longer duration. Following successful IAT no further treatment was required in 44% of cases, reconstruction was needed in 26% and angioplasty in 23%, one major amputation was performed. Unsuccessful lysis resulted in reconstruction in 40% of cases. Overall, the limb salvage rate was 89%. Major complications occurred in six cases. One patient sustained a fatal CVA and five bled from the catheter insertion site. Two of these patients required an emergency operation and one other, who had an angioplasty immediately following lysis, died. Minor complications included local haematoma formation (16), catheter problems (6), and allergic reactions (2). After insertion of the perfusing catheter, angiograms (median 4, maximum 10) were performed at intervals, with repositioning of the catheter if necessary, until lysis was complete.(ABSTRACT TRUNCATED AT 250 WORDS)

Thigh embolisation in association with bilateral profunda femoris aneurysms

True aneurysms of the profunda femoris artery are rare and are much less common than false aneurysms of this vessel. 1 Profunda artery aneurysms can affect either the main t runk of the artery or its branch~es. Unlike aneurysms of the common femoral artery they are frequently symptomatic. We report a case of bilateral synchronous profunda artery aneurysms. On one side the aneurysm was symptomatic, producing distal embolisation to the thigh.

A comparison of clinical index and ejection fractions in predicting cardiac complications following infrarenal aortic reconstruction

OBJECTIVE To compare the Detsky clinical cardiac risk index with ejection fraction measurements in predicting postoperative cardiac events. DESIGN Prospective study. SETTING District General Hospital. MATERIALS 48 patients undergoing infrarenal aortic reconstruction. CHIEF OUTCOME MEASURES Ejection fractions were measured both by echocardiography and a technetium 99 MUGA scan. MAIN RESULTS Three patients developed four major cardiac events (LVF three, fatal myocardial infarction one). Fourteen patients experienced 15 minor cardiac events (arrhythmia 11, ST segment depression four). The clinical index predicted postoperative cardiac problems (p = 0.0001). There was no correlation between ejection fraction measurement and postoperative cardiac events nor between ejection fraction measurements and the clinical index. Combining the index with ejection fraction measurement provided no additional information over the index alone. CONCLUSIONS Calculation of a clinical index before aortic reconstruction is a simple and reliable way of selecting patients who are at risk of developing postoperative cardiac events.

The use of a simple clinical cardiac risk index predictive of long term outcome after infrarenal aortic reconstruction

OBJECTIVE Assessment of the value of preoperative clinical cardiac risk score (Detsky) in predicting long-term outcome in terms of survival and quality of life after elective aortic reconstruction. DESIGN Prospective assessment of cardiac risk factors using Detskys modification of Goldmans Index. SETTING District General Hospital. MATERIALS Ninety-three consecutive patients undergoing elective infrarenal aortic reconstruction. CHIEF OUTCOME MEASURES After a median follow-up of 50.5 months, surviving patients were interviewed to assess quality of life using a standard Rosser classification. MAIN RESULTS A high pre-operative cardiac risk score (Detsky > 10) was associated with decreased probability of survival, increased likelihood of suffering a non-fatal cardiovascular event, and diminished quality of life at the time of assessment. CONCLUSIONS Preoperative cardiac risk assessment is helpful in predicting long-term outcome.

A prospective survey of patients presenting with abdominal aortic aneurysm.

OBJECTIVES To define the presentation and management of patients presenting with abdominal aortic aneurysm (AAA) DESIGN AND SETTING: A prospective survey was carried out of all patients presenting to hospitals within the Oxford region. MATERIALS AND METHODS Data were collected by one surgeon in each hospital. Full details were collected onto data sheets. RESULTS One hundred and ninety patients presented, 141 electively, 46 with ruptured AAA and three with acute AAAs. In 53 patients presenting electively the aneurysm was small and surveillance started. Fifty-six patients underwent an operation, three patients died. Of 46 patients with a ruptured aneurysm 24 (52%) died. In 11 no operation was carried out and all of these patients died within 24 h. Operative mortality was 13 of 35 patients (37%). More patients with a ruptured AAA were transferred to the teaching hospital compared with a district general hospital (p < 0.05). This was reflected in a lower operative mortality in the teaching hospital. CONCLUSIONS The presentation of AAA in this study was approximately 15 per 100,000 population. Approximately one-third of patients presenting electively had small AAAs which required surveillance. A further third underwent an operation, the remaining patients being unfit. Approximately one-quarter of patients with a ruptured aneurysm did not undergo an operation. The operative mortality was 37%.