How safe is internal iliac artery embolisation prior to EVAR? A 10-year retrospective review.

PURPOSE: Internal iliac artery (IIA) embolisation is commonly performed prior to endovascular aneurysm repair (EVAR) of aortoiliac aneurysms to prevent type 2 endoleaks via the internal iliac arteries. The safety of this procedure is controversial due to the high incidence of pelvic ischaemic complications. METHODS: We undertook a retrospective review of all patients undergoing IIA embolisation before EVAR from 2002 to 2012, to determine incidence of, and factors associated with pelvic ischaemia. RESULTS: Eight of 25 patients (32 %) experienced new-onset ischaemia, including erectile dysfunction (4 %), and buttock claudication (28 %) that persisted >6 months in only four patients (16 %). Both bilateral IIA embolisation and a shorter time interval to EVAR correlate with increased risk (p = 0.006 and p = 0.044). No co-morbidities or demographic factors were predictive. CONCLUSIONS: We conclude that IIA embolisation remains a beneficial procedure, however, to minimise the risk of buttock claudication we advise against both bilateral IIA embolisation and short time intervals between embolisation and subsequent EVAR.

The effect of carotid stenting on endarterectomy practice--A single institution experience.

OBJECTIVES: The number of operations performed per surgeon is thought to determine the quality of carotid endarterectomy (CEA) surgery. The advent of carotid artery stenting (CAS) threatens to reduce the volume of CEA. This paper assesses CEA and the effects of the introduction of CAS service on outcomes. DESIGN: Retrospective cohort study. METHODS: Clinical data and results of CEA were reviewed retrospectively for the treatment of carotid stenosis, between January 1988 and December 2010. CEA patients were grouped into those treated before and after the introduction of CAS to our hospital in 2001. RESULTS: 757 patients underwent a CEA between 1988 and 2010. The perioperative stroke rate prior to the introduction of CAS was 4.9%, and 3.3% after stent introduction in 2001. In this latter period, 85.5% had symptomatic stenosis which suggests that the patients were not low risk. The major adverse event rate (inclusive of death and myocardial infarction) post introduction of CAS from 2001 to 2010 was 4.1%. There was no correlation between post-operative stroke/MAE and procedure volume, despite the trend of decreasing CEA numbers over time. CONCLUSION: The introduction of carotid artery stenting has led to a decrease in carotid endarterectomy volume. However, outcomes in our high risk patient population are acceptable. Therefore, CEA remains the procedure of choice for carotid artery revascularization.

What next after thermal ablation for varicose veins: non-thermal ablation?

BACKGROUND: Endothermal treatment of the great saphenous vein has become the first line of treatment for superficial venous reflux. Newer treatments, especially non-thermal ablation have potential benefits both for patient acceptability and decreased risk of nerve injury. APPROACH: We describe the current non-thermal options available including advantages and disadvantages. Ultrasound guided foam sclerotherapy avoids the risk of nerve injury, however it is not as effective as endothermal ablation. Mechanochemical endovenous ablation combines mechanical endothelial damage using a rotating wire, with the infusion of a liquid sclerosant (the Clarivein™ system). Reports suggest that this system is safe and effective, eliminating the need for tumescent anaesthesia with no reported case of nerve injury. Finally the VenaSeal™ Sapheon Closure System comprises the endovenous delivery of cyanoacrylate tissue adhesive to the vein causing fibrosis. Peri-operative discomfort seems to be minimal but the complication of thrombophlebitis has been reported in up to 15% of patients. CONCLUSIONS: Non-thermal options promise comparable treatment efficacy without the added morbidity associated with high thermal energies. The potential of treating venous reflux without the risk of nerve damage may change how surgeons approach venous disease.

Concurrent colorectal malignancy and abdominal aortic aneurysm: a multicentre experience and review of the literature.

OBJECTIVES: There is lack of consensus regarding concurrent vs. staged approaches, and the prioritisation of staged procedures in cases presenting with colorectal carcinoma (CRC) and abdominal aortic aneurysm (AAA) synchronously. We aim to present our experience, review the literature on this therapeutic dilemma and examine the role of endovascular aortic repair (EVAR). DESIGN, MATERIALS AND METHODS: An observational study of the experience of two centres and a systematic review of the published literature. RESULTS: Twenty-four patients were identified from the prospective databases of two tertiary referral centres between 2001 and 2006. Intervention for both malignancy and aneurysm was performed in 13 patients. In 10 patients, cancer resection was performed initially and was followed by open aneurysm repair (n=3) or EVAR (n=7). Two patients (AAA diameters: 7.0 and 8.0cm) underwent EVAR prior to colonic resection. One patient was selected for synchronous surgery. There were no interval AAA ruptures, graft infection or postoperative mortalities. Literature review identified 269 such cases; of these 101 were treated by combined surgery. In staged surgery, there were nine interval aneurysmal ruptures and one aortic graft infection. CONCLUSIONS: In our experience, staged management can be undertaken, without interval aneurysmal rupture. EVAR has an evolving role in preventing delay in CRC management, in high-risk patients, and during combined intervention.

Making the case for cardiovascular screening in Irish males: detection of abdominal aortic aneurysms, and assessment of cardiovascular risk factors.

INTRODUCTION: AAA screening programmes have proven to be beneficial and cost effective worldwide for males greater than 65 years of age, with 4.9% males of 65-75 years of age having an un-diagnosed AAA at screening, resulting in a 42% reduction in the risk of rupture in an English population. This study assessed the incidence of AAA and risk factors for atherosclerosis in Irish males of 55-75 years. METHODS: From April 2006 to December 2007, males between the ages of 55 and 75 years, living within the catchment area of Blanchardstown Hospital were invited for AAA screening using duplex ultrasound and cardiovascular risk factor screening. RESULTS: 1.9% (17/904) of the study population had previously un-diagnosed aneurysms detected, with sizes ranging from 3.0 cm to 5.8 cm (0.6% in 55-65 years old (yo) and 4.2% in 65-75 yo, p<0.01). 33% (302/904) of patients had hyperlipidaemia, while 16% of those with a previous diagnosis of hyperlipidaemia, were inadequately controlled on the test date. 31% of patients had a single elevated blood pressure reading, meriting further investigation for possible hypertension. 3% (28/904) of all patients had a raised glucose levels which had not previously been identified and of those who had a previous history of DM, 46% had abnormal glucose levels. 16% of patients (93/573) were morbidly obese (BMI>30) and 64% (292/573) were overweight. CONCLUSION: The incidence of AAAs in 65-75-year-old men is similar to international figures. This study confirms that screening for hyperlipidaemia, hypercholesterolaemia, obesity and hypertension may be worthwhile in all males over 55 years, while AAA screening should be reserved for 65-75-year-old Irish males.

Virtual reality simulation in endovascular surgical training.

BACKGROUND: Shortened trainingtimes duetothe European Working Time Directive (EWTD) and increased public scrutiny of surgical competency have led to a move away from the traditional apprenticeship model of training. Virtual reality (VR) simulation is a fascinating innovation allowing surgeons to develop without the need to practice on real patients and it may be a solution to achieve competency within a shortened training period. METHOD: A Medline search was performed to identify studies and commentaries on the use of VR simulators in endovascular training. FINDINGS: Three studies on carotid stenting and four on peripheral vascular angioplasty demonstrate that simulator training is a valid, feasible and acceptable training tool. One randomised study reports that these skills learned on simulators are transferable to the operating room. CONCLUSION: VR simulators have a role in competency based, structured training of vascular interventionalists and should improve patient safety.

Traumatic inferior gluteal artery pseudoaneurysm and arteriovenous fistula managed with emergency transcatheter embolization.

We present a case of blunt trauma to the buttock resulting in an inferior gluteal artery pseudoaneurysm and arteriovenous fistula. The characteristic diagnostic features on CT angiography and digital subtraction angiography (DSA), along with the emergency percutaneous management of this traumatic vascular injury, are described. A review of the literature demonstrates inferior gluteal artery pseudoaneurysm is a rare condition, while successful treatment with glue embolization is previously unreported.

Perforation of a retrocaecal appendix presenting clinically as a right lumbar abscess.

Presentations of acute appendicitis represent an ongoing challenge to surgeons. This case of retrocaecal perforated appendicitis presented clinically as a right lumbar abscess, with the concomitant new diagnosis of type 2 diabetes mellitus in a 66-year-old male. This case emphasises the importance of an abdominal CT scan in any patient presenting with unusual sepsis near the abdomen.

Perforated retrocaecal appendix presenting as right lumbar abscess.

BACKGROUND: Acute appendicitis is common in older patients, however, the presentation may differ from the younger population and it is often complicated by coexistent disease and delays in presentation. AIMS: This case report describes an unusual presentation of acute appendicitis in an elderly patient and also demonstrates a unique anatomical pathway of disease extension. In addition, this case report highlights the advantages of CT in preoperative evaluation and subsequent management of these protean presentations of acute appendicitis. METHODS: This report describes a case of an asymptomatic retrocaecal perforated appendicitis which presented clinically as a right lumbar abscess with surrounding cellulitis, and was further complicated by a concomitant new diagnosis of type 2 diabetes mellitus in a 66-year-old male. CONCLUSION: Elderly or immunocompromised patients presenting with cellulitis or a cutaneous abscess of the abdominal wall or lumbar region may benefit from an abdominal CT to demonstrate an intraperitoneal source of sepsis.

Synchronous appendiceal tumours.

Primary appendiceal neoplasms are a rare clinical and pathological entity. We report a case of synchronous appendiceal tumours of different histological types which presented as a symptomatic palpable and radiologically apparent mass in the right iliac fossa. This case demonstrates the importance of pre-operative diagnosis of these neoplasms, as it may alter the surgical approach and obviate the need for additional surgery. Furthermore, some of the controversies associated with the management of an appendix mass in the elderly population are discussed.

A new look at an under-diagnosed poorly treated condition: restless legs syndrome.

Restless legs syndrome (RLS) is a common condition that is difficult to diagnose. However, once correctly diagnosed, its management is straightforward and evidence-based. The purpose of this article is to familiarise clinicians with both the symptoms and diagnostic criteria for RLS and to elucidate secondary and often curable causes of this prevalent condition. There is also a concise review of its pathophysiology and current management strategies. The authors hope this article will raise awareness of this condition among clinicians and in doing so improve the quality of life for the patients affected by it.

Adult intussusception--need for en-bloc resection.

BACKGROUND: Adult intussusception is an uncommon surgical presentation AIMS: We report a case of adult intussusception, review the literature and discuss the optimal management. METHODS: We describe a woman who presented with severe abdominal pain and a large supra-umbilical mass. Ileocolic intussception was confirmed on CT, and a laparotomy and en-bloc resection were carried out. Postoperatively she made an uneventful recovery. CONCLUSION: Adult intussusception is a rare clinical presentation. En-bloc resection should be the surgical treatment of choice in the majority of cases due to the high percentage of malignant lead points.