Changing to endovenous treatment for varicose veins: how much more evidence is needed?

Surgical ligation and stripping of varicose veins has been the accepted treatment for almost a century but within the last decade this has been challenged by endovenous thermal and chemical ablation methods. Surgery is not without significant complications including paraesthesia and has reflux recurrence rates of up to 54% at five years, even though it has been shown to provide significant health-related quality of life benefits cost-effectively. Ultrasound-guided foam sclerotherapy, endovenous laser ablation and radiofrequency ablation are all consistently proving to be at least as beneficial as surgery, without the same complications and with less post-procedure morbidity and more rapid recovery. This article presents a review of the latest published evidence and comparative analysis of vein surgery and it's alternatives. Endovenous treatment under local anaesthesia in a clinic room or office-based setting is now being recognized internationally as an acceptable standard for dedicated venous practice in a cost-effective environment. Although more long-term comparative trials of these innovative methods compared with surgery are desirable, many centres are now conducting trials testing the latest endovenous device technologies with each other to support the development of contemporary pathways of care. Patients are entitled to a range of treatment strategies, particularly when complex and recurrent venous disease has such unacceptably high surgical complication and recurrence rates compared to endovenous alternatives. There is questionable logic in procrastinating until there is more convincing evidence. Now is the time for vascular surgeons to enhance their ultrasound skills and future-proof their venous practice for the benefits of patients and institutions.

Microcoil embolisation of mycotic cystic artery pseudoaneurysm: a viable option in high-risk patients.

Mycotic cystic artery pseudoaneurysm is a rare complication of cholecystitis, of which the main treatment has been cholecystectomy plus ligation of the cystic artery. We highlight our experience with successful coil embolisation of this condition without the need for surgical intervention. This is followed by a comprehensive review of the literature regarding management of this unusual condition.

Primary cutting balloon angioplasty for treatment of venous stenoses in native hemodialysis fistulas: long-term results from three centers.

AIM: To evaluate the technical success and patency rates following primary cutting balloon angioplasty for venous stenoses in native dialysis fistulas. METHODS: Forty-one patients (26 men, 15 women; age range 26-82 years, average age 59 years) underwent 50 (repeat procedures in 9 patients) primary cutting balloon (PCB) angioplasty procedures in three institutions by three primary operators. The indication was primary stenosis in 21 patients, recurrent lesions in 15, and immature fistulas in 5. A PCB was used alone in 17 cases, but was followed by a larger standard balloon in 33 cases. Follow-up included ultrasound, flow analysis and urea reduction ratio, and ranged from 2 to 30 months (mean 14 months). RESULTS: The technical success rate was 98%. All procedures were relatively painless. Two PCBs burst and 4 leaked, but without causing any morbidity. Nineteen fistulas were still working at last follow-up. Primary patency rates at 6, 12, and 24 months using Kaplan-Meier analysis were 88%, 73%, and 34%, respectively, and the primary assisted patencies were 90%, 75%, and 50%, respectively. CONCLUSION: PCB angioplasty has high technical success and low complication rates. The long-term patency rates are favorable for PCB angioplasty and compare favorably with other series.

Radiological placement of the AshSplit haemodialysis catheter: a prospective analysis of outcome and complications.

BACKGROUND: The AshSplit catheter has recently been introduced as an alternative permanent tunnelled haemodialysis catheter, combining ease of insertion with good long-term patency and flow rates. METHODS: Data were collected prospectively on all the long-term tunnelled haemodialysis (AshSplit) catheters inserted radiologically between January 1998 and March 1999. Information was obtained regarding the initial insertion, ongoing catheter function and re-intervention up to September 1999. RESULTS: A total of 118 catheters were inserted in 88 patients (50 male), median (range) age 64 (20-86) years. Ultrasound guidance was used routinely and the right internal jugular vein was used in 80 (68%) cases. Initial complications occurred in 14 (11.9%) cases, which included local haemorrhage, carotid artery puncture, and air embolism. Infection occurred in 34% of catheters (2.4/1000 catheter days). Line thrombosis was documented in 20% (1.2/1000 catheter days). Satisfactory mean urea reduction ratio (URR) of 63 was obtained for all catheters. There were 47 re-interventions, mainly for fibrin sheath stripping (34) and/or thrombectomy (25). Total catheter duration was 21600 days with a 1 month cumulative survival of 87% (Kaplan-Meier probability 85%). At the end of the study, 20 (17%) catheters were still functioning, 39 (33%) had been removed electively, and 22 (18%) patients had died with a functioning catheter in situ. Catheter infection was implicated in four deaths. CONCLUSIONS: Radiological insertion of the AshSplit catheter is well tolerated, providing reliable short- and long-term dialysis access. Radiology also has a role in maintaining patency. As with all tunnelled catheters, infection remains a problem.

Acquired coropulmonary and bronchopulmonary anastomoses occurring in association with pulmonary arterial occlusion and veno-occlusive disease generating potential coronary steal.

The development of collateral circulation is a general vascular response which is well characterised in the heart. The most common precipitant of this is ischaemia and the most common manifestation is intra coronary collateralisation. Collateral flow between the heart and other thoracic structures is also documented albeit rarely and can be congenital or acquired. In this case report we define a unique case of collateral flow between the coronary and pulmonary circulations in a complex case of mediastinal fibrosis.