Simon G. Darke

Venous ulceration and saphenous ligation.

Over an 8-year period prospective series of 213 consecutive patients with venous ulceration of 232 limbs has been studied. By means of clinical, hand-held Doppler ultrasound and comprehensive ascending and descending venography examination, it was possible to identify underlying morphological abnormalities and on the basis of these to divide patients into four principal types. Type I:4%--ankle perforator incompetence alone; Type II:39%--ankle perforator and saphenous incompetence; Type III: 35%--primary deep incompetence (usually associated with perforator and saphenous incompetence); Type IV:22%--patients with postphlebitic damage. This study reports the outcome of Type II patients that have been treated by saphenous ligation alone (no perforator ligation). Healing was maintained over a mean period of 3.5 years in all but five patients. In these, other factors were shown in retrospect to be contributory to failed healing. It is concluded, therefore, that approximately 40% of venous ulcers can be ascribed to a combination of incompetence of saphenous and ankle perforating veins and that medium-term healing can be achieved in at least 90% of these by saphenous ligation alone.

The morphology of recurrent varicose veins

Over an 18-month period, of 444 patients referred for treatment for varicose veins, 95 (21%) had had previous surgery. By means of clinical hand-held Doppler and in selected venographic evaluation these were subdivided into three groups as follows. Type 1:29 of the 95 patients had recurrence through thigh perforators. Type 2:10 patients had developed incompetence through a second saphenous system, in nine of the 10 in the short saphenous having had previous long saphenous surgery. Type 3:46 patients had recurrent sapheno-femoral incompetence and 10 sapheno-popliteal incompetence. A persistent long saphenous trunk in the thigh was present in approximately two-thirds of cases of types 1 and 3. In over half of the type 3 patients saphenofemoral recurrence was by reconstitution of the junction by neovascularisation. These morphological studies demonstrate why there may be an increased risk of recurrence if the long saphenous trunk is not excised at the time of primary surgery.

Diagnostic Features and Management of Bacterial Arteritis with False Aneurysm Formation

Primary bacterial arteritis with false aneurysm formation is an uncommon condition. This report presents seven patients admitted to one unit over a 5-year period. Interesting aspects of the clinical presentation are discussed. The importance of surgical debridement, extra-anatomic bypass, antibiotic therapy and antibiotic irrigation of the infected aneurysm cavity is stressed. The relative merits of extra-anatomic bypass and in situ grafting for aortic infection are discussed. By following these principles, this series of patients have had a successful surgical outcome and all the signs of infection have been eradicated.

Value of Routine Computed Tomography in the Preoperative Assessment of Abdominal Aneurysm Replacement

Abstract. This study compares the findings of conventional computed tomography (CT) and ultrasound (US) imaging in the preoperative evaluation of patients with abdominal aortic aneurysm (AAA). It also assesses the impact of preoperative CT-derived information on operative strategy. A prospective study was conducted of 96 patients who were considered for aortic aneurysm surgery, and the operative notes and US and CT reports were analyzed to assess correlation of findings and influence of CT on operative tactics. Agreement between CT and US in sizing the aneurysm was generally good. CT was more accurate than US for defining the upper and lower extent of the aneurysm (75% and 83%, respectively, with CT, compared to 47% and 41% with US), although it had a high false positive rate (48%) for juxtarenal disease. Its advantage over US in regard to showing other intraabdominal pathology was only marginal, and it predicted an inflammatory reaction in only two of the five cases. Its influence on operative strategy was minimal: Of the 25 cases where a juxtarenal aneurysm was predicted by CT, only 2 patients did not have surgery as a result. CT is a relatively expensive and time-consuming procedure, and its ionizing radiation, however small, and potential side effects from contrast material hypersensitivity cannot be ignored. In light of the above findings, we suggest that CT scanning need not be routinely employed in the preoperative workup of elective aortic aneurysm repair but should be used only in selected cases.