Y.C. Chan

Drug-eluting stents and balloons in peripheral arterial disease: Evidence so far

Restenosis by myointimal hyperplasia after peripheral arterial angioplasty or stenting is a major problem limiting its long‐term efficiency and patency, and may lead to recurrent symptoms. Drug‐eluting devices which inhibit the proliferation of neo‐intimal growth of vascular smooth muscle cells may prevent restenosis. The aim of this article is to examine the evidence in published literature on the use of drug‐eluting devices in the treatment of peripheral arterial diseases. A systematic literature review was undertaken of all published literature on this subject using Medline and cross‐referenced. All published relevant articles on the use of drug‐eluting stents and balloons in peripheral arterial disease were used. Cochrane Central Register of Controlled Trials and electronic databases were also searched for on‐going studies. Published results from randomised studies such as the SIROCCO I and II Trials and the THUNDER study, together with single cohort studies, are now available. There are on‐going studies comparing drug‐eluting and non‐drug‐eluting devices. Evidence from the published literature suggests that drug‐eluting stents and balloons are safe and effective in preventing restenosis after peripheral angioplasty. However, drug‐eluting devices are more expensive and many are limited to single‐use only. It is anticipated that results from all the on‐going studies may allow a meta‐analysis to show whether these preliminary data can translate into a clinically applicable cost‐effective strategy in combating restenosis after peripheral angioplasty or stenting.

Abdominal complications from crack cocaine.

Not only is cocaine a powerfully addictive and dangerous drug of abuse, the use of the purified cocaine derivative crack has also reached epidemic proportions. Apart from causing fatal cardiorespiratory complications, crack cocaine is capable of producing surgical emergencies, which may or may not be associated with the pharmacology of cocaine itself. This is a report of crack-induced pneumoperitoneum, the mechanism of which seemed to be related to the prolonged Valsalva manoeuvre during crack smoking. Other differential diagnoses of crack related pneumoperitoneum are also discussed.

Changes in Inflammatory Response after Endovascular Treatment for Type B Aortic Dissection

This present study aims to investigate the changes in the inflammatory markers after elective endovascular treatment of Type B aortic dissection with aneurysm, as related to different anatomical features of the dissection flap in the paravisceral perfusion. Consecutive patients with type B aortic dissections with elective endovascular stent graft repair were recruited and categorized into different groups. Serial plasma levels of cytokines (Interleukin-1β, -6, -8, -10, TNF-α), chemokines (MCP-1), and serum creatinine were monitored at pre-, peri- and post-operative stages. The length of stent graft employed in each surgery was retrieved and correlated with the change of all studied biochemical parameters. A control group of aortic dissected patients with conventional medication management was recruited for comparing the baseline biochemical parameters. In total, 22 endovascular treated and 16 aortic dissected patients with surveillance were recruited. The endovascular treated patients had comparable baseline levels as the non-surgical patients. There was no immediate or thirty day-mortality, and none of the surgical patients developed post-operative mesenteric ischaemia or clinically significant renal impairment. All surgical patients had detectable pro-inflammatory mediators, but none of the them showed any statistical significant surge in the peri-operative period except IL-1β and IL-6. Similar results were obtained when categorized into different groups. IL-1β and IL-6 showed maximal levels within hours of the endovascular procedure (range, 3.93 to 27.3 higher than baseline; pu200a=u200a0.001), but returned to baseline 1 day post-operatively. The change of IL-1β and IL-6 at the stent graft deployment was statistically greater in longer stent graft (p>0.05). No significant changes were observed in the serum creatinine levels. In conclusion, elective endovascular repair of type B aortic dissection associated with insignificant changes in inflammatory mediators and creatinine. All levels fell toward basal levels post-operatively suggesting that thoracic endovascular aortic repair is rather less aggressive with insignificant inflammatory modulation.

Conservative management of delayed retrograde type A aortic dissection after successful hybrid endovascular repair of distal arch aneurysm.

Abstract Retrograde Type A aortic dissection following successful endovascular treatment of thoracic aortic disease is not uncommon. We report a case where the primary pathology was distal aortic arch aneurysm without dissection, and the retrograde type A dissection occurred four months after successful hybrid endovascular management with right to left carotid bypass and stent-graft with a Cook Zenith device. As the patient was not medically fit for sternotomy and repair of Type A aortic dissection, progress was monitored with serial CT scans. This case demonstrates that delayed retrograde type A dissection can occur even in cases when there was no previous aortic dissection, and that in selective patients who are poor candidates for major aortic surgery, a conservative approach can be adopted.

Managing the diabetic foot with the use of vacuum-assisted closure: a call for more studies

Denial is common in religion, politics, medicine and all of life. The dictionary definitions range from refusing to comply with a request, to refusing to believe that a statement or allegation is true. An extreme form of denial is the rejection of a doctrine or belief in spite of historical evidence of its validity. Recently, the existence of the Holocaust has been denied by Islamic extremists. Though most members of the Islamic faith recognise the absurdity and danger of these views it is often only confrontation with the historical evidence that translates the knowledge into the painful recognition of exactly what happened. Over time I have been exposed to many reminders of the consequences of one form of denial or another. The rollcall of the dead in the two World Wars and the Vietnam Memorial Wall in Washington still chill the soul – war is a consequence of denial of the rights of others, taken to the extreme. A recent visit to Prague brought home to me the scale of Jewish suffering. The Pinkas Synagogue was transformed in 1958 into a memorial to the 77,297 Czech Jews killed during the Holocaust. In silence their names and date of birth, death or transportation to the camps are viewed – every wall is covered as part of the world’s longest epitaph. A room of children’s drawings from the Jewish ghetto of Terezı́n is a memorial to and reminder of the cruelty inflicted on the innocent – of 8000 children deported only 242 survived their wartime suffering. I am not Jewish but that does not deny me the right to believe in their pain – denial would only serve to protect me from reality. Denial in medicine is an important defence against the reality of a threatening illness. It needs to be handled carefully and not with aggression because of the emotional pain that could follow. At times denial of this sort can impede the medical care available or cause distress and confusion amongst family and close friends. Asking about a person’s perception of their illness and their doubts and fears is an important way of tackling denial. Both fear of cancer, which may delay diagnosis when curable, and unnecessary fear of death when cancer is cured, are not uncommon consequences of denial. Dependency on alcohol is common and often denied. It is common in the medical profession and may contribute to the high suicide rate. The period of denial varies, and may last the lifetime of the individual who is unable to take the responsible decision not to drink. The denial extends to colleagues, family and friends who tolerate and cover for but do not confront the problem – a denial circuit in need of interruption. In the political arena the denial of an alcohol problem or sexual orientation issues (homosexuality is an issue, not a problem, but becomes a problem if denied) can have consequences that extend beyond the individual to threaten the stability of the party involved. Re-organising the National Health Service 19 times in 20 years is denied by politicians as being a cause for inequalities of care and funding chaos. It is denied that the increase in hospitalacquired infections is connected to the failure to close infected wards due to the need to achieve waiting list targets, and it is denied that the decline in cleanliness is connected. Over the past 20 years the number of cleaners working in the National Health Service hospitals has fallen by 40,000. Denial prevents a problem being tackled or creates a problem where none existed. Whilst it may be considered protective at an individual level, the compromise as a consequence may be emotionally challenging. Having to issue a denial identifies a problem not addressed fully. Living a life of denial can only be accepted as part of a personal religion (in its broadest sense): otherwise denial can only lead to deception.

Delayed presentation of popliteal pseudo-aneurysm following soccer football injury.

Development of pseudo-aneurysm of the popliteal artery usually results from trauma, infection, or iatrogenic causes after orthopedic operations. This is to our knowledge the first reported case in the worlds literature of a delayed presentation of a large above-knee popliteal artery pseudo-aneurysm following a soccer football injury. The pseudo-aneurysm severely compressed the native artery, and open exploration with surgical vein-patch repair of the artery was chosen in preference to endovascular stent-graft in view of the compressive symptoms and large size of the chronic pseudo-aneurysm. This case highlights the importance of imaging such as duplex ultrasound, computed tomography, or magnetic resonance angiography if symptoms persist after sports injury.

Development of Simultaneous Anastomotic False Aneurysms at Both Ends of an Autologous Vein Graft caused by Methicillin-Resistent Staphylococcus Aureus (MRSA)

Abstract Methicillin-resistant Staphylococcus aureus (MRSA) infection is a well recognised problem, especially in vascular surgical patients with synthetic bypass grafts. This is to our knowledge the first report in the literature of the development of anastomotic false aneurysms at both ends of an autologous vein graft, as a result of MRSA infection within the vascular wall.

How important are metalloproteinases in aortic dissection

angle when asked to identify a site for chest drain insertion as defined by the BTS guidelines, with 24% too low which would increase the likelihood of diaphragmatic or viscus injury (5). Competency-based training is aimed at improving and standardising core skills but there are concerns regarding the reduction in working hours and its impact on actual exposure and training opportunities. It should be clear that ‘see one, do one, teach one’ is no longer acceptable practice. In the current UK acute medicine curriculum, doctors at stage ST1 ⁄ 2 are expected to be competent in performing chest drain insertion using the Seldinger technique by the end of their core training. There is no specific guidance on the number of procedures required to be performed, only that training should lead to independent practice and this may lead to pressure to assume competence too early. Judging by the investigation above this seems to be the main area for improvement. Good clinicians not only need to be competent in skills before they perform them independently but also aware of their limitations. They should always feel comfortable in seeking senior advice no matter what level they have attained in their training. Miller’s triangle describes levels of competence from knows, knows how, shows how to does (6). The ‘shows how’ level can be in a simulated environment and, with reasonable models around to simulate chest drain insertion, it should no longer be considered acceptable for the first ‘shows how’ to be on a patient. Imaging by ultrasound is more widely available and should be used if there is any doubt or difficulty in initial aspiration. Physicians may develop expertise in the use of ultrasound and the more widespread referral to radiologists for drain insertion might further reduce the expertise of training grade staff in medicine. There are cost implications and issues related to the availability of this service, particularly ‘out of hours’. Evidence supports ultrasound-guided thoracentesis as it is associated with a lower incidence of complications than those reported for thoracentesis without direct imaging guidance (7). The current incidence of chest drain complications is unknown as there is likely to be under-reporting of cases and there is no data on the actual number of procedures performed. A preventable fatal complication as a direct consequence of this procedure is unacceptable. Action at both a local and national level is required to determine the true extent of the problem and to develop safe standards of practice. Chest drain insertion needs to be regarded as a high-risk procedure and all precautions should be taken to minimise harm to the patient. How will you consent your patient for chest drain insertion in the future?

Do not be fooled by angiography in renovascular disease

A 73-year-old hypertensive gentleman who had previously undergone an infrarenal abdominal aortic aneurysm repair presented with thoracic back pain. Abdominal examination revealed a non-tender, pulsatile mass in the epigastrium. There were no carotid bruits and he had a full complement of supraaortic and infrainguinal pulses. Intra-arterial digital subtraction angiography revealed a type II thoracoabdominal aortic aneurysm down to the level of the previous infrarenal graft, associated with apparent stenoses of the renal arteries (Fig 1). Contrast enhanced computed tomographic (CT) scanning of the aorta showed that these stenoses were due to narrow channels in the thrombus of the aneurysm, and not true arterial stenoses (Fig. 2).