Structural implications of fenestrated stent graft misalignment.

BACKGROUND: Endovascular aneurysm repair is a minimally-invasive method for the treatment of abdominal aortic aneurysms. For aneurysms that involve the visceral arteries, a custom-made stent graft with fenestrations for the branch arteries is required. The purpose of the current study is to evaluate the structural impact of misaligned fenestrations with respect to luminal patency and proximal aortic neck apposition in an in vitro model. METHODS: A custom apparatus was used to evaluate seven Anaconda and three Zenith fenestrated stent grafts. All stent grafts were evaluated at 10° increments of stent/fenestration misalignment up to 80°. Images were captured at each interval and the luminal cross-sectional area and wall apposition were measured. RESULTS: The Anaconda stent graft, which has an unsupported main body, demonstrated a linear reduction in luminal patency at increasing angles of misalignment (P < 0.0001). Stent/fenestration misalignments of 20° and 80° resulted in decreases in mean luminal patency of 14% and 54% respectively. The Zenith stent graft demonstrated a similar decrease in luminal patency, starting at misalignments of ≥40° (P < 0.0001). However, with stent/fenestration misalignments of ≥30°, apposition between the Zenith stent graft and the simulated aortic neck was compromised suggesting the creation of a type Ia endoleak. CONCLUSIONS: Both the Anaconda and Zenith devices behave adversely at extreme angles of misalignment with luminal narrowing in the Anaconda device and loss of wall apposition in the Zenith device; however, both stent grafts appear to be equivalent at low angles of misalignment.

The Impact of Compliance with Imaging Follow-up on Mortality After Endovascular Abdominal Aortic Aneurysm Repair: A Population Based Cohort Study.

OBJECTIVE: Compliance with regular imaging follow-up after endovascular aortic aneurysm repair (EVAR) is inconsistent, and evidence of benefit from scheduled long-term surveillance is limited. This study sought to characterize the association between post-EVAR imaging frequency and long-term survival. METHODS: Using administrative health databases for the province of Ontario, Canada, a cohort of patients was identified who underwent EVAR between 2004 and 2014. Minimum appropriate imaging follow-up (MAIFU) was defined as a CT scan or ultrasound of the abdomen within 90 days of EVAR as well as every 15 months thereafter. Multivariate time to event analyses characterized the association between compliance with MAIFU over time and all-cause mortality. RESULTS: 4988 patients treated by EVAR were identified. Median follow-up was 3.4 years (IQR 2.0-5.3 years) and 90 day mortality was 1.6%. Among those who survived over 90 days, 87% (N = 4251 of 4902) underwent at least one CT scan or ultrasound of the abdomen within 90 days, but only 58% (N = 2859 of 4902) went on to meet MAIFU criteria. Infrequent imaging correlated with lower follow-up by a vascular surgeon, but not with infrequent primary care or specialist consultations. Consistently meeting MAIFU criteria was associated with a lower risk of death when compared with missing the first imaging follow-up within 90 days (HR 0.82, 95% CI 0.69-0.96, p = .014), or when compared with having first imaging follow-up within 90 days but subsequently not meeting MAIFU criteria (HR 0.78, 95% CI 0.68-0.91, p = .001). A larger proportion of the follow-up period meeting MAIFU criteria was associated with a lower risk of death. CONCLUSIONS: These data support efforts to improve compliance with imaging surveillance after EVAR.

Using a multimedia presentation to improve patient understanding and satisfaction with informed consent for minimally invasive vascular procedures.

OBJECTIVE: As vascular procedures become more complex, patient understanding of their treatment(s) can become more difficult. We wished to evaluate the utility of multimedia presentations (MPs) to improve patient understanding of their vascular interventions. METHODS: Patients undergoing endovascular aneurysm repair (EVAR), peripheral angioplasty, Hickman catheter and peripherally inserted central catheter (PICC) insertion were randomized into a control group receiving traditional verbal consent, and a MP group that were shown a two minute simplified video of their procedure on an iPad™ computer in addition to the traditional verbal consent. After obtaining consent, all patients completed a questionnaire assessing their comprehension of the procedure, and satisfaction with the consent process. Satisfaction was rated on a 5 point Likert scale with 5 being 'very helpful' in understanding the procedure. RESULTS: Ninety-three patients were recruited for this study, 62% of which were male. The intervention significantly increased total comprehension in all procedure types controlling for procedure type (multimedia vs. control; F = 9.14, P = .003). A second ANOVA showed there was a significant main effect by intervention (F = 44.06, p < .000) with those in the intervention group showing higher overall satisfaction scores after controlling for surgery type. CONCLUSION: This study suggests that patients find the use of MP during the consent process to be helpful in patient understanding and that there is improved satisfaction. Given the rapid rate of innovation in vascular interventions, increased regular use of MPs to help patients understand their procedures would be beneficial in the care of patients undergoing vascular interventions.

Continuous regional anaesthesia provides effective pain management and reduces opioid requirement following major lower limb amputation.

OBJECTIVES: Postoperative stump pain after major lower limb amputation is a significant impediment to the recovery of amputees. The vast majority of patients require opioid analgesics following surgery, which are associated with opioid-related side-effects. Here, we investigate whether intraoperative placement of a peripheral nerve stump catheter followed by continuous infusion of local anesthetic is as effective at pain control as current analgesic practices. If beneficial, this procedure could potentially reduce post-amputation opioid consumption and opioid-related adverse effects. METHODS: A retrospective chart review was conducted of 198 patients over a 4-year period who had undergone a major lower limb amputation for indications related to peripheral vascular disease. Postoperatively, 102 patients received a perineural catheter were compared to 96 patients who did not. The primary outcomes of this study were the amount of morphine equivalents used in the first 72 hours postoperatively and postoperative pain intensity in the first 24 hours. RESULTS: A total of 198 lower-limb amputations were selected for analyses. Multiple regression analyses indicated that perineural catheter use was associated with a lower cumulative postoperative opioid consumption over the first 72 hours but not postoperative pain scores at 24 hours. Perineural catheter use led to a 40% reduction in opioid use during the first 72 hours postoperatively. Mixed model repeated measures analysis demonstrated that this opioid reduction was consistent over time. Other variables related to total opioid use included age, pre-surgical chronic pain, pre-surgical opioid use, patient-controlled analgesia. CONCLUSIONS: Continuous perineural infusions of local anesthetic are a safe and effective method for reducing post-amputation opioid analgesic medications after major lower limp amputation.

Anomalous splenic artery aneurysm.

Aneurysms of the splenic artery are the most common visceral aneurysm. A splenomesenteric trunk, which involves the splenic artery arising from the superior mesenteric artery (SMA), is rare and occurs in less than 1% of patients. Thus splenic artery aneurysms (SAAs) with an anomalous origin from the SMA are quite rare. We report our experience with the surgical management of a 2.6-cm aneurysm involving a splenic artery arising from the SMA in a 40-year-old woman. This was treated with surgical resection with preservation of the spleen. A discussion about SAAs and the management of aneurysms arising from a splenomesenteric trunk follows.

Patient knowledge of peripheral vascular disease in an outpatient setting: an Achilles heel?

Peripheral vascular disease (PVD) has numerous modifiable risk factors. This study aimed to establish patients' awareness of risk factors and causes of PVD and their understanding of mechanisms of secondary prevention. A prospective survey of awareness of PVD among patients attending a tertiary vascular clinic for management of peripheral vascular disease was undertaken. Institutional review board approval was granted. Statistical analysis was performed using SPSS version 18.0 software. There was a 100% response rate, with 97 participants (53 male). Seventeen patients (19%) reported an interval of greater than six months from the onset of symptoms to first seeking medical attention with their General Practitioner. Only 19 (20%) could correctly identify 3 or more risk factors for peripheral vascular disease. Patients have limited awareness of PVD and its consequences. Educational initiatives are needed to encourage patients to seek early medical attention and raise awareness of modifiable risk factors in the community.

Infected pseudoaneurysm of the superficial femoral artery in a patient with Salmonella enteritidis bacteremia.

Mycotic aneurysms, defined as irreversible dilation of an artery due to destruction of the vessel wall by infection, are rare but are associated with a high risk of rupture if not treated promptly. The case of a healthy 52-year-old smoker who presented with pyrexia, rigors, night sweats and severe right leg pain with swelling is presented. He was diagnosed with a superficial femoral artery mycotic aneurysm, with Salmonella enteritidis as the causative agent. He was treated with high-dose antibiotics, local debridement and autologous reconstruction. A high index of suspicion is needed to make the correct diagnosis in these cases. Prompt surgical intervention and antimicrobial therapy are the cornerstones of treatment to reduce the associated high morbidity and mortality.

Les anévrismes mycosiques, définis comme la dilatation irréversible d'une artère causée par une destruction de la paroi découlant de l'infection, sont rares mais s'associent à un risque élevé de rupture s'ils ne sont pas traités rapidement. Les auteurs exposent le cas d'un fumeur en santé de 52 ans qui a consulté à cause d'une pyrexie, de frissons, de sueurs nocturnes et de graves douleurs à la jambe droite accompagnées d'un œdème. Il a reçu un diagnostic d'anévrisme mycosique de l'artère fémorale superficielle causée par une Salmonella enteritidis. Il a reçu de fortes doses d'antibiotiques, un débridement local et une reconstruction autologue. Il faut un indice de présomption élevé pour poser le bon diagnostic. Une intervention chirurgicale et une thérapie antimicrobienne amorcées rapidement sont la pierre angulaire du traitement pour réduire la morbidité et la mortalité élevées qui s'associent à ce problème.

Endovascular ruptured abdominal aortic aneurysm repair--setting up your hospital for an endovascular approach.

In recent years, major improvements have been made, making elective repair of abdominal aortic aneurysm (AAA) a safe procedure. In selected series, mortality rates are less than 5%. Many of the patients with AAA, however, remain asymptomatic until they present with rupture. Once rupture has occurred, the overall mortality approaches 90%. Despite many advances in the management of ruptured AAA, the mortality rate of conventional open surgery has not improved significantly during the last 15 years. Over the last decade, endovascular techniques have been used increasingly to repair AAA, and there is increasing evidence that endovascular aneurysm repair (EVAR) is technically feasible and safe for ruptured AAA. This review studies the evidence and aids the clinician in setting up a practice to manage rAAAs utilizing an endovascular approach.

Neoadjuvant aortic endografting.

The advent and success of endovascular repair of abdominal aneurysms led to the development of catheter-based techniques to treat thoracic aortic pathology. Such diseases, including thoracic aortic aneurysms, acute and chronic type B dissections, penetrating aortic ulcers, and traumatic aortic transection, challenge surgeons to perform complex open operative repairs in high-risk patients. The minimally invasive nature of thoracic endografting provides an attractive alternative therapy. We present two cases of covered stent grafts deployed in the thoracic aorta to perform resection of the aortic wall infiltrated by malignancy in order to avoid a major vascular intervention and a traditional vascular graft interposition. This may become a potential new utility for aortic endografts.

Iliopsoas abscess: a re-emerging clinical entity not to be forgotten.

Iliopsoas abscesses are relatively rare clinical entities. They present with subtle and non-specific symptoms and as a result the diagnosis is often delayed, leading to significant morbidity and mortality. With an increasing number of immunocompromised patients in the population the prevalence of this condition is set to rise. Therefore, early diagnosis and appropriate management remain a challenge for clinicians. We present three patients with iliopsoas abscesses, two of which were primary and one of which was secondary to Crohn's disease. The average age of patients was 59 years and both patients with primary psoas abscesses were male. All presented with non-specific symptoms. Psoas sign was present in only one patient. CT confirmed the diagnosis in all cases. Treatment consisted of appropriate antibiotic cover and associated percutaneous drainage. The psoas abscess that was secondary to underlying Crohn's disease was subsequently treated with surgical excision of the affected segment of bowel and lavage of the abscess cavity. A high index of suspicion is required to ensure the accurate and early diagnosis of this rare clinical entity. Abdominal CT scanning remains the gold standard for diagnosis. Management is with appropriate antibiotics and adequate drainage. This can be achieved by either percutaneous or surgical drainage. Such treatment can reduce the overall morbidity and mortality of this condition.

Neo-adjuvant chemoradiotherapy in advanced rectal carcinoma: a note of caution.

Rectal cancer remains a major source of morbidity and mortality with its prognosis relating directly to the initial stage of the disease at presentation. This report highlights the potentially serious morbidity and mortality, which may be associated with neo-adjuvant chemoradiotherapy in advanced rectal cancer, emphasising the need for thorough discussion with patients on the risks and benefits of such treatment.

Virtual reality technology and surgical training--a survey of general surgeons in Ireland.

BACKGROUND: Virtual Reality Technology (VRT) is a validated method of training in industry but only recently has found a place in the postgraduate surgical curriculum. AIMS: We surveyed 143 Irish consultant surgeons to ascertain their opinions on this topical issue. METHODS: The survey consisted of 22 questions to which the consultants were asked to respond by choosing from a 5-point Likert scale. RESULTS: Sixty-five per cent responded. A majority of 72% had seen VRT but only 47% had 'hands on' experience. Forty-six per cent believed that they were poorly informed regarding available technologies. As consultants became more informed about VRT significant differences were seen with regard to attitudes regarding the role of VR in skills in surgical training (p<0.05) and in the ability to define teaching objectives (p<0.005). CONCLUSIONS: Our survey suggests that the underuse of the current offerings is not due to a perceived lack of interest on the part of the surgical trainers. Suppliers of these programmes have a responsibility to adequately educate and collaborate with all parties involved to improve overall benefit from these simulators.

Nicorandil related anal ulcer.

BACKGROUND: Anal ulceration is uncommon. Patients are typically referred because of severe anal pain, bleeding, discharge, and ulceration. It is important to exclude anal carcinoma, and to consider more unusual causes. METHODS: A 74-year-old lady presented with severe anal pain and ulceration. This was subsequently noted to be related to nicorandil, a potassium channel activator used in the treatment of angina. Discontinuation of nicorandil and faecal diversion allowed symptom relief and ulcer healing. CONCLUSION: Knowledge of the association between nicorandil and anal ulceration is essential in order to appropriately diagnose and manage this condition.

Pseudo-aneurysm of the hepatic artery after laparoscopic cholecystectomy: A case report.

Iatrogenic injuries to hepatic artery system may evolve to pseudoaneurysms in the late postoperative period. Although rare, pseudoaneurysms after laparoscopic cholecystectomy can occur, are a serious clinical entity and very difficult to detect.We present a case of iatrogenic pseudoaneurysm after laparoscopic cholecystectomy. The onset of symptoms occurred 5 days after an uneventful operation. Endovascular coil embolization for a large pseudoaneurysm was unsuccessful and open surgery was conducted. Review of the literature reveals fifty-four more cholecystectomy-related pseudoaneurysms. The site of injury was the right hepatic artery in 61% of the cases and the presenting symptom was hemobilia in two-third of the patients. Embolization was performed in 82% of the cases and surgery undertaken in the remaining 18%.Knowledge of the condition should result in early diagnosis and thus limit the resultant morbidity. Embolization is the first line of treatment and surgery is reserved for more complex injuries and cases with life-threatening rupture of the aneurysm.

Aneurysmal degeneration of vein conduit used for vascular reconstruction-Case report and literature review.

INTRODUCTION: Popliteal artery aneurysms (PAA) are the most prevalent form of peripheral arterial aneurysms. Greater saphenous vein grafts and endoaneurysmorrhaphy remains the mainstay therapy for open repair of PAA. True aneurysmal degeneration of lower extremity infrainguinal autologous vein grafts are relatively rare and its etiology is not completely understood. CASE PRESENTATION: We present a case of a 57-year-old man with recurrent autologous venous graft aneurysmal dilatations following a surgical popliteal artery aneurysm repair. DISCUSSION: The pathogenesis of true aneurysmal graft dilatation remains speculative with possible pathogenesis including progression of underlying atherosclerosis, systemic dilating diathesis, autologous venous graft varicosities, low-grade infections and post-stenotic dilatations. Management of venous graft aneurysms should be subjected to the same criteria as other aneurysms. Diagnosis requires a high index of suspicion. The initial study of choice is duplex ultrasonography as it can diagnose the aneurysm and distinguish it from other popliteal masses, provide accurately measurements and identify thrombus within the aneurysm. Once diagnosed, surgical repair should be performed as soon as possible as graft dilatation tends to occur overtime and is typically followed by a rapid increase in size over a short period of time. CONCLUSION: Aneurysmal degeneration of autologous saphenous venous graft following PAA repairs occur infrequently. Its etiology remains largely speculative. Accurate diagnosis and early surgical intervention can prevent progression of aneurysmal dilatation and minimize the potential of complications.

Stump appendicitis: a rare but important entity.

A case of right lower quadrant pain in a 35-year-old male who underwent an appendicectomy 14 years previously is presented. Recurrent appendicitis with perforation was noted in an appendiceal stump on exploratory laparotomy. Although rare, inlammation of the appendiceal stump can occur and is still an important clinical entity. It is difficult to diagnose pre-operatively. A wide spectrum of causes in the differential diagnosis of right lower quadrant pain of the abdomen and a previous appendicectomy in a patient's history may delay the diagnosis. Knowledge of the condition should permit the physician to make an early diagnosis and, thus, limit the resultant morbidity.

Hybrid resection of a giant thigh plexiform neurofibroma.

PRESENTATION OF CASE: Authors present a case of a 55 year old patient with Type 1 neurofibromatosis (NF1) and a very large right thigh plexiform neurofibroma. The patient had increasing difficulty with mobilization due to this enlarging bulky mass. Preoperative embolization reduced the bleeding risk at surgery allowing successful gross resection of the mass by a multidisciplinary surgical team. Limb function was restored to normal. DISCUSSION: Massive plexiform neurofibromatosis is a rare expression of von Recklinghausen's disease or NF1. These large masses result in severe disfigurement and significant functional disability. They are extremely vascular and there is potential for malignant transformation. CONCLUSION: These massive tumors require complex preoperative, intraoperative and postoperative management strategies with involvement from a multidisplinary team. We discuss the challenges of surgical intervention and to discuss the current literature.

Unusual cause of a perforated stomach.

A case of gastric perforation 2 months following insertion of a gastric balloon is reported. The literature is reviewed regarding the complications and success rates inherent in such balloon devices. This is the first case report of an intra-gastric balloon causing gastric perforation.

The European Working Time Directive: a survey of surgical specialist registrars.

On 1 August 2004 junior doctors in the Irish health care system and other healthcare systems throughout Europe will no longer be excluded from the provisions of the European Working Time Directive. Their working hours will then be limited by law, first to 58 hours a week and then, by 2009, to 48 hours. This will demand even more profound changes for the Irish health care system than seen so far. This survey was undertaken to elicit the opinions and first-hand experiences of surgical specialist registrars (SpRs) throughout Ireland on different working patterns, and the impact of being on-call on their surgical training and lives. The working time directive will undoubtedly shake the foundations of surgery in Ireland and Europe, and meeting the directive by 2009 will require fundamental change if both it and the challenge of providing first class surgical training and safe patient care are to be met.

Evaluation of patient knowledge regarding oral anticoagulants.

Warfarin sodium [Coumadin] is widely used since its introduction in 1954. The dosage varies from individual to individual and is subject to adjustment due to interactions with other medications and alcohol. It is therefore important for the patient to be educated fully regarding warfarin therapy as outside the narrow therapeutic range either failure to prevent thromboembolism or serious bleeding with potential fatal complications may occur. Patient comprehension of the risks of anticoagulation, tablet recognition skills and knowledge of complications of warfarin therapy were evaluated in 150 patients attending the anticoagulation clinic in a Dublin teaching hospital. The majority, 125 (83%) perceived that they had received education about the therapy. Concomitant aspirin was avoided by 125 (83%) patients, but 25 (17%), thought it safe in combination with warfarin; 33 (22%) believed that alcohol was safe in combination with warfarin. When asked about the colours and strengths of warfarin tablets, 125 (83%) patients identified the 1 mg tablet correctly. Only 105 (70%) identified the 3 mg tablet and 98 (65%) the 5 mg tablet correctly. In 42 (28%), patients could not describe their current therapy. Potential complications from over- and under-dosage with warfarin were unknown to 89 (59%) and 90 (60%) patients respectively. This study suggests that patient knowledge regarding anticoagulation therapy is not optimal. A significant group may be at risk from serious complications because of inadequate knowledge. We suggest improving patient knowledge may improve control, reduce complication and therefore reduce the burden on the health service.