Large bowel impaction by the BioEnterics Intragastric Balloon (BIB) necessitating surgical intervention.

A case of large bowel impaction caused by migration of a BioEnterics Intragastric Balloon (BIB) is presented. The literature is reviewed regarding both the use and the complications inherent in such balloon devices. This is the first reported case of an intragastric balloon impacted in the colon 9 months after insertion.

The aetiology of vein graft strictures: a prospective marker study.

In a prospective series of 74 femoro-popliteal vein grafts (34 in situ and 40 reversed), 22 strictures were identified by duplex scanning in 18 grafts (24.3%). Thirteen strictures were identified in 10 of 40 reversed grafts and 9 strictures were identified in 8 of 34 in situ grafts. Grafts were marked at operation using surgical clips at sites of all valves, tributaries, clamps and venotomies, since these have all been suggested as potential sources of graft strictures. These were prospectively studied as part of a detailed graft surveillance programme by intravenous digital subtraction angiography and duplex scanning. A total of 377 valves, 681 tributaries, 15 clamps and 2 venotomies were identified. Twenty-two strictures were detected in 18 grafts, an incidence of 24.3%, but only one lesions coincided with a specific marked area (a valve site). Duplex examination in 34 in situ grafts identified 10 residual valve cusps in seven grafts. In none of these was there any evidence of turbulence or flow disturbance, and none progressed to form a stricture. It is concluded that there is no correlation between valve sites, tributaries, clamp sites or residual valve cusps and the development of vein graft strictures.

In situ versus reversed femoropopliteal vein grafts: long-term follow-up of a prospective, randomized trial.

In a prospective, randomized trial, 226 patients undergoing femoropopliteal bypass for lower limb ischaemia were allocated to reversed (123 patients) or in situ (103) techniques. The groups were comparable for age, sex, incidence of diabetes, and indications for surgery. Eleven veins were rejected at operation, nine in the reversed group and two in the in situ group, leaving 114 reversed and 101 in situ grafts for study. Cumulative patency rates were not significantly different between reversed and in situ grafts at any time up to 6 years after operation, with primary patency rates at 1, 3 and 5 years of 84.8, 69.5 and 62.4 per cent for reversed grafts and 79.9, 71.2 and 63.5 per cent for in situ grafts. Small vein grafts (< 4 mm in diameter) were associated with patency rates at 1, 3 and 5 years of 63.5, 46.7 and 36.0 per cent compared with 93.9, 82.5 and 75.9 per cent for vein grafts > or = 4 mm in diameter (P < 0.002, log rank test). The patency rates of small veins employed in situ and reversed were similar. The in situ technique confers neither short- nor long-term advantage over reversed vein grafting for femoropopliteal bypass.

The use of an adjuvant arterio-venous shunt in prosthetic femoro-crural bypass.

In limb threatening ischaemia the use of a long prosthetic graft to the distal calf vessels may be the only alternative to a primary amputation. Patency rates in these situations are relatively poor and the use of an adjuvant arteriovenous fistula (AVF) at the distal anastomosis to increase the velocity of flow above the thrombotic threshold seems logical. We present follow-up of up to 8 years in a series of 80 consecutive reconstructions to the distal crural vessels using human umbilical vein with an adjuvant AVF. The mean age of the patients was 68.3 years and 12 (15%) were diabetic. The indication for surgery was limb threatening ischaemia in all cases; 41 (51.2%) for established necrosis and the remaining 39 (48.8%) for severe ischaemic rest pain. The mean ankle:brachial index was 0.23. The common ostium (CO) configuration of AVF was used in 50 cases (62.5%) and pre-anastomotic in 30 cases (37.5%). The volume blood flow in 49 cases, measured peroperatively using an electromagnetic flowmeter, was 116 ml/min (+/- 62.5) with the shunt closed and 283 ml/min (+/- 132.2) with the shunt open (p less than 0.01, Student's t-test). Cumulative patencies of all grafts were 39% at 2 years and 29% at 4 years. The age of the patient and the type of AVF, common ostium or pre-anastomotic, had no significant effect on patency rates, but grafts under 70 cm in length had a cumulative patency at 2 years of 42.5% compared to 13.5% for those over 70 cm in length (p less than 0.01). Cumulative patencies were derived by life table analysis and compared using the log rank test. The size of the recipient vessels at the distal anastomosis is thought to be crucial to the outcome of these operations. An increase in velocity of flow produced by an AVF, increases the wall shear stresses at this site and may lead to an increased tendency for intimal hyperplasia. It may be possible to mitigate these effects by the use of additional surgical or pharmacological techniques and further studies are required.

An evaluation of patients with severe intermittent claudication and the effect of treatment with naftidrofuryl.

A randomized placebo-controlled study was undertaken in 188 patients with severe intermittent claudication attending two vascular clinics in Manchester and Liverpool. After a 4-week run-in period, patients received active or placebo treatment for 24 weeks. Patients were assessed on a treadmill prior to the 4-week run-in period, at randomization, and at 8, 16, and 24 weeks. Outcome was measured in terms of change in pain-free walking distance, maximum walking distance, and pressure indices. In this severe claudication population, in which the patients presented with a mean pain-free walking distance of 60 m, an intention-to-treat analysis demonstrated that the outcome in the naftidrofuryl-treated group was significantly better than in the group receiving placebo (p = 0.045). Additionally, 7% of patients in the naftidrofuryl group deteriorated compared with 22% in the placebo group (p = 0.005). Of the various risk factors that were recorded during the study--smoking habits, the presence of hypertension, diabetes, obesity, and duration of illness--only duration of illness had a significant influence on outcome. Maximum walking distances alone were not significantly influenced by treatment, but the use of a combined index of pain-free walking distance, maximum walking distance, and pressure indices to record success or failure confirmed a significant treatment effect (p = 0.047). A higher incidence of minor gastrointestinal symptoms was recorded in the naftidrofuryl-treated group. Treatment with naftidrofuryl was shown to prevent or slow the deterioration observed in a group of patients with severe claudication over a 24-week period.