T.R. Magee

A meta‐analysis of 21 178 patients undergoing open or endovascular repair of abdominal aortic aneurysm

Several studies have compared outcomes after elective open and endovascular approaches to abdominal aortic aneurysm (AAA) surgery, with varying results.

Endovascular and Open Approaches to Non-thrombosed Popliteal Aneurysm Repair: A Meta-analysis

OBJECTIVE Endovascular repair of popliteal artery aneurysms is a relatively new technique that is still undergoing evaluation. The aim of this study was to compare outcomes following open and endovascular approaches. METHODS All published studies comparing outcomes following open and endovascular popliteal aneurysm were included. Endpoints included operative duration, length of stay, and postoperative complications including short-term patency rates. Outcomes were combined using a random-effects meta-analytical technique and differences assessed using odds ratios (OR), weighted mean difference (WMD) and log hazards ratio (HR). RESULTS Three studies comprising 141 patients (37 endovascular; 104 open) were included. No significant differences in patient characteristics were seen. Operative duration was significantly longer for endovascular repair (WMD 120 minutes, p<0.001). Thirty day graft thrombosis (OR 5.05, p=0.06) and reintervention (OR 18.80, p=0.03) were more likely following endovascular repairs. Postoperative length of stay was shorter in the endovascular group (WMD--3.9 days, p<0.001). There was no significant difference in long-term primary patency rates (HR 1.70, p=0.53). CONCLUSIONS Endovascular repair of popliteal artery aneurysms offers similar medium-term benefits as an open repair. However, short-term graft thrombosis and reintervention rates are significantly greater. With the current technology it is difficult to justify endovascular treatment of popliteal aneurysms.

Subintimal angioplasty for superficial femoral artery occlusion: poor patency in critical ischaemia

INTRODUCTION Subintimal angioplasty has been proposed for the treatment of long segment occlusive disease and for patients with critical limb ischaemia (CLI) with significant co-morbidity. There is no consensus as to short- and long-term patency. We present our experience with this technique. METHODS Between 1995 and 2000, 43 consecutive patients (48 limbs) underwent subintimal angioplasty for superficial femoral artery occlusions. Outcome measures were haemodynamic and/or symptomatic patency. RESULTS Technical success was achieved in 14/17 limbs with CLI (82%) and 30/31 (97%) with intermittent claudication (IC). There were 7 complications (15%), 6 occurring in the claudicant group. The median occlusion length was 10 cm for CLI and 6 cm for IC. Patency at 12 and 36 months, on an intention-to-treat basis, was 69% and 58% for claudicants and 25% and 25% for patients with CLI (P = 0.0005 and P = 0.0044, respectively). Following only technically successful procedures, 12-month patency was 72% (IC) and 31% (CLI) (P = 0.009). Patients with occlusions > or = 10 cm were more likely to re-occlude than those < 10 cm (12-month patency 60% versus 25%;P = 0.037). CONCLUSIONS In this series, short- and long-term patency in patients with CLI is poor. Subintimal angioplasty in the treatment of CLI should be reserved for those patients not fit for surgical bypass.

Early Results of Retrograde Transpopliteal Angioplasty of Iliofemoral Lesions

AbstractPurpose: To assess whether the retrograde transpopliteal approach is a safe, practical and effective alternative to femoral puncture for percutaneous transluminal angioplasty (PTA). Methods: Forty PTAs in 38 patients were evaluated. Intentional subintimal recanalization was performed in 13 limbs. Ultrasound evaluation of the popliteal fossa was carried out 30 min and 24 hr postprocedurally in the first 10 patients to exclude local complications. All patients had a follow-up of at least 6 weeks. Results: The indication for PTA was critical ischemia in seven limbs and disabling claudication in the remainder. Stenoses (single or multiple) were present in 24 and occlusion in 15. The superficial femoral artery (SFA) was the commonest segment affected (36) followed by common femoral artery (CFA) in four and iliac artery in four. Technical success was achieved in 38 of 39 limbs where angioplasty was carried out. In one limb no lesion was found. Immediate complications were distal embolization in two and thrombosis in one. None of these required immediate surgery. There were no puncture site hematomas or popliteal arteriovenous fistulae. Symptomatic patency at 6 weeks was 85%. Further reconstructive surgery was required in three limbs and amputation in two. Conclusion: The transpopliteal approach has a high technical success rate and a low complication rate with a potential to develop into an outpatient procedure. It should be considered for flush SFA occlusions or iliac disease with tandem CFA/SFA disease where the contralateral femoral approach is often technically difficult.

Five-year retrograde transpopliteal angioplasty results compared with antegrade angioplasty

INTRODUCTION Retrograde transpopliteal angioplasty (PA) is a potentially useful alternative technique for endovascular treatment of infra-inguinal arterial disease when antegrade transfemoral puncture (FA) is technically not possible or appropriate. This study aimed to investigate the outcomes of PA compared with FA during a 5-year period. PATIENTS AND METHODS A retrospective study was performed to assess 88 PA and 275 FA performed between January 2003 and January 2008. Assessments of patients, indication for procedure, disease site, stenosis severity, procedure outcomes and time to further intervention were recorded. RESULTS FA was used to treat more patients with critical ischaemia (42.2% vs 30.7%; P = 0.014)). PA was used to treat more proximal superficial femoral lesions (P < 0.001) and occlusive lesions (P = 0.001). Overall, 84.1% of PA and 82.5 % of FA were technically successful. There was no difference in local puncture site complication rates. Significantly more FA resulted in distal thrombus/embolism (8.4% vs 3.4%; P = 0.044). Further intervention was required in 27.3% of PA and 36.0% of FA. The time interval to re-intervention was not different between the groups. CONCLUSIONS PA is safe with comparable success rates and long-term outcomes to an FA. PA is a useful alternative approach for treating occlusive, proximal disease.

A Survey of Current Attitudes of British and Irish Vascular Surgeons to Venous Sclerotherapy

AIM To determine current practice amongst vascular surgeons regarding venous sclerotherapy. METHOD A postal questionnaire was sent to 350 members of the Vascular Surgical Society of Great Britain and Ireland. RESULTS There were 218 replies (62%). Forty surgeons (18.3%) never injected varicose veins (VV) although six injected venous flares. Most surgeons (n = 168, 77.1%) reserved sclerotherapy for residual VV postoperatively. Primary varicose veins without proximal incompetence were injected by 152 (69.7%) and recurrent VV without proximal incompetence by 141 (64.7%). Sixteen surgeons only injected residual postoperative VV. Few surgeons injected VV in the presence of proximal incompetence. Where specified, 46% of respondents were injecting fewer VVs than in previous years. Only 5% were injecting more. By contrast, 44% were injecting more venous flares than previously (p < 0.001). Eight different sclerosants were used, the commonest being STD (146 surgeons) and Sclerovein (33). The median number of patients treated with sclerotherapy was 11-50 per year compared with 51-150 per year who were operated upon. The median time advised for compression was 2 weeks (range--a few minutes--2 months). Treatment was repeated at a median of 4 weeks (0-6 months). Thirty-two surgeons obtained written consent. All but eight respondents discussed potential complications, the commonest being staining and ulceration. Forty-six surgeons had patients who had experienced serious complications, the commonest being ulceration. There was one reported death from a pulmonary embolus. CONCLUSION Sclerotherapy is being used less frequently for VV. Most surgeons use it for residual VV and for those without proximal incompetence.

Natural history of the ectatic aorta.

OBJECTIVES To define the natural history of ectatic abdominal aortas and to assess the clinical need for follow-up. DESIGN Abdominal aortas were considered ectatic if they were diffusely and irregularly dilated with a diameter less than 3 cm. Ectatic aortas were identified either by AAA screening or as incidental findings. Patients who had only one scan were excluded from the study. Clinical data were analysed. SETTING Two district general hospitals in Wales and England. SUBJECTS 116 patients (90 men). RESULTS : The median age of patients was 71 years (range 48-90). Co-existing risk factors included hypertension (75), IHD (22), PVD (8), diabetes (3), COAD (14), stroke (5), popliteal aneurysm (1), malignant disease (3) and 4 had a family history of AAA. The median follow-up was 24 months (range 5-72). The median and maximum growth rate of the ectatic aortas were 0.65 and 14.4 mm/year respectively. In three patients the expansion rate was more than 5 mm/year. In 22 patients the ectatic aorta became aneurysmal, reaching a diameter greater than 3 cm. There were no ruptures and no elective repairs. Two deaths occurred due to IHD. CONCLUSIONS : This study demonstrates that if ectatic aortas do expand they do so very slowly. However, 22 of the 116 (19%) became aneurysmal in a follow-up of two years. Once identified ectatic aortas should be scanned at intervals of three years.

Spontaneous Rupture of the Superficial Femoral Artery Treated with Endovascular Stent-Grafting

Spontaneous rupture of the superficial femoral artery (SFA) is rare. It may occur in the presence of an SFA aneurysm or in a nonaneurysmal, but usually atherosclerotic, artery. Previously these ruptures have been treated by surgical exclusion, often with bypass grafting. We report a case of spontaneous rupture of a nonaneurysmal SFA treated successfully with endovascular stent-grafting.

Computed tomography-detected abnormalities following conventional abdominal aortic aneurysm (AAA) repair.

PURPOSE To determine how time since the operation influences vascular abnormalities following conventional infrarenal abdominal aortic aneurysm (AAA) repair. METHODS In 47 patients computed tomography was performed 1 to 12 years following the aneurysm repair. Aortic diameters at different levels were measured and other abnormalities recorded. RESULTS Significant correlation was found between time since operation and diameter of the suprarenal aorta (R=0.51, P<0.001) but not with aortic neck diameter (R=-0.10, P=0.48) or diameter of the prosthetic graft (R=0.07, P=0.66). However, measured diameters of graft and aortic neck showed a significant positive correlation (R=0.40, P=0.005). CONCLUSIONS Dilatation of the suprarenal aorta has a different pattern from aortic neck dilatation. The latter showed correlation with the diameter of the prosthetic graft. This may be of interest for future design of endovascular stent-grafts.

Reduction in varicose vein services: impact on operative training.

INTRODUCTION This study examines the impact of rationing varicose vein operations on operative training on a general surgical unit with a vascular interest. PATIENTS AND METHODS Log-books of middle-grade surgeons were analysed for 3-month periods before and after a decision by the local Primary Care Trust to ration varicose vein referrals. Number, intermediate equivalents and type of operations were recorded, whether they were general or vascular cases and whether the trainee had carried out or assisted with the operation. RESULTS There was a slight fall in the total number of operations in which the middle-grade surgeons were involved (208 to 186). There was a significant increase in general surgical cases with the fall in number of varicose vein operations (P < 0.0001). The fall in case-load and work-load operative training in vascular surgery was compensated by an increase in general surgical cases (P = 0.0003). This was largely due to increased number of hernia repairs (P = 0.0035). CONCLUSIONS From the point of operative training, a vascular unit in a district general hospital would not be sustainable following withdrawal of varicose vein services. However, this can be off-set by increasing general surgical case-load to fill the gap created.