Isolated tibial vessel disease: treatment options and outcome.

Tibial vessel disease is an important cause of limb ischaemia, particularly in diabetics. Revascularisation by angioplasty and bypass is increasingly feasible. The aim of this study was to review treatment and outcome in patients with this patterns of disease. We have performed 25 procedures in 20 patients since September, 1989. Six patients (5 diabetic) underwent 9 tibial angioplasties for stenotic lesions causing critical ischaemia or short-distance claudication. In 6 procedures there was single vessel run-off. Eight angioplasties were radiologically successful with a median increase in ankle-brachial index (ABI) of 0.15 [range: 0.00-0.44] at a median follow-up of 9 months. A further 4 patients (3 diabetic) with critical ischaemia underwent popliteal-distal, in-situ vein bypass for tibial occlusions. Distal anastomosis was onto the dorsalis pedis artery or distal anterior artery. Three grafts remain patent with successful limb salvage and ABI's greater than 1.0. Angioplasty is also useful for distal disease progression following femoro-popliteal bypass. Six patients with "at-risk" grafts underwent 8 tibial angioplasties for stenotic lesions in distal run-off. Radiologically, 6 procedures were successful with a median increase in ABI of 0.21 [range: 0.00-0.38] at a median follow-up of 7 months. There were less favourable results when a "graft-distal" bypass performed to salvage an occluded femoro-popliteal graft with diseased run-off vessels. Three of 4 grafts reoccluded within 3 months, 2 patients requiring amputation. We advocate an aggressive policy towards localised distal disease causing foot ischaemia.

Standardised trunk asymmetry scores. A study of back contour in healthy school children.

This paper reports a new method for expressing numerically asymmetry of the contour of the back in a forward-bending position. Information is given at three spinal levels (T8, T12 and L3) for 636 schoolchildren aged 8 to 15 years. Rib-hump and lumbar-hump scores were standardised to create trunk asymmetry scores (TASs) making comparison possible between children of different age, size and sex. Two groups of children were defined: those with clinically straight spines (585 children); and those with clinical evidence of lateral spinal curves (51 children). In the children with clinically straight spines the main findings were: about 1:4 had objectively detectable rib and lumbar humps; female-to-male ratios were 1.2:1 for the thoracic region and 1.4:1 for the lumbar region; right humps were about 10 times more common than left; TASs in the boys and girls at each spinal level had normal distributions about means to the right of zero (where zero represents perfect symmetry); at T8 and T12, a wider scatter of TASs in girls than in boys; at L3, larger TASs in girls than in boys; a relation between shortening of one lower limb and a contralateral hump on the back; and no relation to age (except at L3), stature (corrected for age) or handedness. The findings are discussed in relation to possible causes of back contour asymmetry, early diagnosis of scoliosis by screening, sexual dimorphism and significance for the pathogenesis of idiopathic scoliosis. Ten children with clinically straight spines and larger TASs, and 42 out of 51 children with clinical evidence of lateral spinal curves in the forward-bending position attended for radiographic examination. Twelve children had "scoliosis curves" of 11 degrees or more as defined by the Scoliosis Research Society. The results are reported in relation to TASs, spinal curve angle (Cobb) and vertebral rotation.

Long-term follow-up of Swanson's silastic arthroplasty of the metacarpophalangeal joints in rheumatoid arthritis.

77 patients with rheumatoid arthritis, 62 female and 15 male, underwent metacarpophalangeal joint arthroplasty on 375 joints using the Swanson design silicone rubber spacer between 1976 and 1985. Retrospectively, 48 of these patients were evaluated by postal questionnaire and 35 of them also underwent objective assessment at intervals ranging from five to 14 years post-operatively. Objective variables recorded included range of active motion, recurrence of ulnar drift and radiographic appearances. Both in the early and late stages, the vast majority of patients were satisfied with the outcome, with abolition of pain, correction of deformity and improved range of motion. There was some loss of mobility with time. However, functional improvement was maintained in the majority. Complication rates compare favourably with other reported series and no case of silicone synovitis was diagnosed. We agree with previous studies that the procedure is useful for lasting relief of pain and enhancement of a patient's sense of well-being and is associated with few complications.

Vein quality in infrainguinal revascularisation: assessment by angioscopy and histology.

The concept of vein quality has been slow to gain widespread acceptance, but an increasing body of evidence suggests that vein quality is relevant to the success of bypass grafting for peripheral vascular disease. The angioscope represents an additional tool for monitoring and preparing vein grafts during infrainguinal revascularisation. Within the overall theme of vein quality, this paper presents the cumulative experience with vascular endoscopy at Bristol Royal Infirmary. In clinical studies, the diagnostic role of angioscopy in quality control was evaluated by grafting preexisting, angioscopically detected, intraluminal abnormalities and correlating them with histological appearances. There were significant associations between angioscopy/histology grades and graft patency. To enable quantification of images, an innovative computerised video image processing method has been developed and validated against simultaneous ultrasound measurements of segments of saphenous vein. The therapeutic applications of angioscopy in vein graft preparation were studied prospectively in patients undergoing in situ femoropopliteal/distal bypasses by randomisation to full angioscopic or conventional preparation. There was a significant reduction in wound morbidity. Completion angioscopy and arteriography were complementary in the detection of technical defects. Harvested vein was maintained in organ culture to assess further the influence of pre-existing pathology and the potentially traumatic effects of angioscopy on development of neointimal hyperplasia. There was a significant correlation between the extent of pre-existing abnormality and smooth muscle cell proliferative activity in culture and although angioscopy caused endothelial cell loss, this did not stimulate neointimal hyperplasia in vitro. This work confirms that vein quality can be evaluated prospectively by angioscopy and that substandard vein is associated with inferior patency rates. Angioscopic and histological evaluation, together with vein organ culture studies, have definite application in helping to elucidate the mechanisms underlying graft failure.

Influence of compression stockings on lower-limb venous haemodynamics during laparoscopic cholecystectomy.

Lower-limb venous haemodynamics were studied prospectively in 40 patients (24 women, 16 men of median age 52 years) undergoing laparoscopic cholecystectomy. Patients were randomized to wear compression stockings during surgery or no stockings. All received subcutaneous heparin prophylaxis. Venous capacitance and outflow were measured non-invasively before, during and after pneumoperitoneum. In the group without compression stockings (20 patients) venous capacitance and outflow decreased during pneumoperitoneum in most patients. In the group wearing stockings (20 patients) the changes were less pronounced or abolished. There was a significant difference between the groups in venous capacitance and outflow ratios at mid-operation: median (interquartile range) 0.89 (0.56-1.16) and 0.89 (0.56-1.15) respectively in the group without stockings versus 1.48 (1.09-2.19) and 1.71 (1.20-2.19) respectively in that with stockings (P < 0.001). Pneumoperitoneum creates a significant resistance to venous return. Compression stockings counteract the changes observed.

Immunocytochemical staining of pS2 protein in fine-needle aspirate from breast cancer is an accurate guide to response to tamoxifen in patients aged over 70 years.

Fine-needle aspirates from 52 breast cancers in 50 patients over 70 years of age were immunocytochemically stained for pS2 protein. All patients were treated with tamoxifen 40 mg/day and followed up at intervals of 2 months. The size of the tumour was serially assessed with calipers and portable ultrasonography. Change in tumour size was confirmed mammographically. Clinical monitoring was performed bind of the pS2 status. Twenty-five tumours were pS2 positive, of which 23 showed a significant response; ten went into complete remission (mean time to complete remission 6.8 (range 2-14) months) and 13 demonstrated partial remission (mean follow-up 8.9 (range 6-19) months). Two tumours remained static. Twenty-seven tumours were pS2 negative and none of these responded to tamoxifen; six remained static (mean follow-up 11.5 (range 6-14) months) and 21 progressed (mean time to progression 7.0 (range 3-14) months) (P < 0.001). Immunocytochemical assessment of fine-needle aspirates from elderly women with breast cancer accurately predicts a worthwhile response to tamoxifen.

Duplex assessment of run-off before femorocrural reconstruction.

BACKGROUND: This study was a prospective evaluation of colour duplex imaging for the assessment of distal run-off before femorocrural reconstruction. METHODS: Patients with critical ischaemia who required a distal bypass underwent preoperative run-off assessments using dependent Doppler, arteriography and duplex imaging by a vascular surgeon, radiologist and technologist respectively; each was blinded to the findings of the others. Preoperative data were compared with intraoperative clinical findings and completion flow studies/ arteriograms. RESULTS: Forty-three consecutive patients (33 men, ten women; mean age 78 (range 53-95) years; 12 diabetic) undergoing 44 femorocrural reconstructions for critical ischaemia were assessed. The 30-day primary cumulative graft patency for the series was 86 per cent. Dependent Doppler correctly predicted a suitable run-off vessel in 21 limbs but was indeterminate in four and unrecordable in 19. Arteriography correctly predicted a suitable run-off vessel in 32 cases, but was indeterminate in six and failed to demonstrate run-off in three patients. Arteriography suggested an inferior vessel in three cases. Duplex correctly predicted a suitable run-off vessel for all 44 grafts. CONCLUSION: Duplex imaging is superior to arteriography for preoperative assessment of distal run-off for femorocrural reconstruction.

Postocclusive hyperaemic duplex scan: a new method of aortoiliac assessment.

Aortoiliac duplex scanning, while accurate, is time-consuming and technically demanding. This study aimed to develop a fast, non-invasive screening test for aortoiliac disease. Colour duplex scanning was used to record common femoral Doppler ultrasonographic waveforms following 3 min of arterial occlusion using a thigh cuff in 25 patients with normal aortoiliac segments and 25 patients with significant aortoiliac disease. The latter patients had a prolonged period of postocclusive hyperaemic flow compared with the former. End diastolic velocity, 70 s after cuff release, was a significant discriminant between the two groups (sensitivity of 88 per cent, accuracy of 92 per cent). The postocclusive hyperaemic duplex (PHD) test performed well when used prospectively in a further 50 limbs (sensitivity of 86 per cent, accuracy of 84 per cent). The test was more sensitive than femoral pulse palpation and compared favourably with arteriography. The PHD test provides a simple, noninvasive assessment for aortoiliac disease that can be performed on the initial outpatient clinic visit.

Carotid endarterectomy: are we under-performing?

An audit of the number of carotid endarterectomies performed over the last 4 years was performed in the south western region. For the years 1990, 1991, 1992 and 1993 the number of cases were 126, 165, 165 and 164 respectively. It is estimated for this region that about 600 operations should be carried out per annum. This under-performance may reflect a lack of knowledge about the potential benefits of surgery.

Detection of sub-critical arterial stenoses by hyperaemic Doppler.

OBJECTIVES: This study assessed the potential of hyperaemic Doppler to detect sub-critical stenoses using a flowrig model. METHODS: Pulsatile flow of a blood substitute was produced in a compliant circuit. A cadaver carotid artery, constricted by a silk suture produced a variable, focal stenosis. Forty-seven stenoses were created in five arteries. Pressure gradients and Doppler measurements were recorded simultaneously across each stenosis at low (200 ml/min) and high (400 ml/min) flow rates. The change in peak velocities between the arterial segment 2cm proximal to the stenosis (V1), and the stenotic jet (V2) were used to calculate three Doppler indices: (i) V2/V1 ratio, (ii) V2-V1 difference, (iii) a modified 'Bernoulli' value. A high flow pressure gradient of > or = 15% of the resting distal pressure (% delta P), represented a significant stenosis. RESULTS: There was improved correlation between Doppler indices and % delta P at high flow (r = 0.87 to 0.88) compared to low flow rates (r = 0.81 to 0.84). Optimum V2/V1 cut off values were determined by received operator characteristics (ROC) curve analysis. At low flow five sub-critical stenoses were not detected (sensitivity 82.8%) yet all but one of these lesions were identified at high flow (sensitivity of 96.6%). The V2-V1 and Bernoulli indices did not improve on the discriminant ability of the V2/V1 ratio. CONCLUSIONS: The V2/V1 ratio is sensitive to haemodynamic changes at enhanced flow rates across ideal arterial stenoses. The potential of hyperaemic Doppler to detect sub-critical lesions and so avoid intraarterial pressure measurements deserves further in vivo study.

Treatment of intermittent claudication: the impact on quality of life.

OBJECTIVES: To measure changes in claudicant's quality of life after surgery, angioplasty or unsupervised exercise. To explore the relationship between clinical indicators of limb perfusion and patient's perception of health change. DESIGN: Prospective study. SETTING: University Hospital vascular outpatients. MATERIALS AND METHODS: 202 claudicants referred for Duplex of lower limb arterial disease over a 12 month period. The short form 36 questionnaire was used to determine quality of life. Ankle pressures and walking distances were determined. MAIN RESULTS: The SF-36 was completed by 186 patients (92%) before and after treatment (34 operative patients, 74 angioplasty and 78 treated by exercise alone). Baseline quality of life was worse in surgical patients. Unsupervised exercise produced minimal changes in quality of life. Angioplasty and operation produced similar, significant improvements in physical functioning and pain. Changes in physical function or pain scores were unrelated to changes in ankle pressure. CONCLUSIONS: Unsupervised exercise programs are unlikely to significantly improve patient's quality of life. The benefits of surgery and angioplasty support a relaxation in the indications for investigation and treatment of claudicants. Patients with impaired perceived health should not be denied treatment on the basis of preintervention ankle pressure or walking distance alone.

Intramuscular diclofenac sodium for postoperative analgesia after laparoscopic cholecystectomy: a randomised, controlled trial.

Laparoscopic cholecystectomy is the surgical treatment of choice for symptomatic gallstones. Nonsteroidal antiinflammatory drugs offer effective analgesia, avoiding the central side effects of opiate drugs. To assess intramuscular diclofenac sodium (Voltarol; Ciba-Geigy) after laparoscopic cholecystectomy, 55 consecutive patients (41 female; 14 male; mean age: 50 years) were randomised to receive either diclofenac or placebo in double-blind fashion. Six patients were withdrawn from study (three conversions to open cholecystectomy; three incomplete documentation). Pain scores were assessed at 4, 24, and 48 h using a linear analogue scale; opiate consumption and time to first oral fluid and food were recorded. In 26 patients receiving diclofenac, median scores at 4 h were 1.6 (range 0-7.6) as compared with 4.1 (range 0-7.6) in 23 control patients (p = 0.05, 95% confidence limits 3.2, 0; Mann-Whitney U test). Nausea scores, return to diet, and time to discharge did not differ significantly between the groups. Intramuscular diclofenac significantly reduces early postoperative pain after laparoscopic cholecystectomy and is worthy of consideration if the procedure were ever undertaken as day case surgery.

Intra-arterial streptokinase infusion in acute lower limb ischaemia.

Between 1986 and 1988, 38 patients (29 men and nine women), median age 65 years (range 38-85 years), underwent local intra-arterial streptokinase therapy for acute lower limb ischaemia. Three patient groups were identified: 15 with acute on chronic ischaemia (group 1), 12 postangioplasty (group 2) and 11 postfemorodistal bypass (group 3). Distal arteriographic run-off was a significant discriminant between success and failure in group 1 (n = 15, chi 2 = 11.5, P = 0.001) and in the overall group (n = 38, chi 2 = 17.2, P less than 0.001). In group 2, four patients with good run-off had an unsuccessful outcome; this was due in all cases to technical problems (haemorrhage in two and intimal dissection in two). In group 3, two patients with good run-off had unsuccessful streptokinase infusions. In both cases the graft failed in the early postoperative period (less than 30 days). By contrast, the four patients whose grafts occluded after 30 days had successful streptokinase infusions and long-term graft patency was achieved by further surgery and balloon dilatation. In all groups, no patient with a poor run-off had a successful outcome following streptokinase administration. The role of local intra-arterial streptokinase therapy in the critically ischaemic limb remains controversial, but these results suggest that an adequate run-off is an important factor in the selection of patients for treatment.

Focal myositis - a new presentation.

This article is a case report and review of literature of a very rare condition, not previously written in general surgical literature, including a new presentation

Preferential use of vein for above-knee femoropopliteal grafts.

OBJECTIVES: Many centres preferentially use polytetrafluoroethylene (PTFE) for above-knee femoropopliteal bypass as surgery is simplified and patency rates are comparable to vein, which is preserved for subsequent revisions or for distal disease progression. In this Unit, vein remains first choice graft material. The aim of this study was to audit our results with respect to above-knee bypass to establish the demand for vein for secondary reconstruction and to document the ultimate fate of the limb. PATIENTS: Between 1983 and 1992, 112 above-knee reconstructions were performed on 109 patients (89 vein and 23 PTFE grafts). PTFE was used where vein was absent or inadequate. Life table analysis of primary graft patency, limb salvage and patient survival up to 36 months follow-up concurs with previously reported series. RESULTS: Twenty-eight vein grafts (31%) and 11 PTFE grafts (48%) occluded during a median follow-up of 64 months (8-116 months). In only four cases was vein required for secondary procedures. The remainder were salvaged by thrombectomy and local procedures for technical problems. Amputation rates following graft occlusion were 12% in the vein group (20% of these being above-knee) as against 26% in the PTFE group (80% above knee). CONCLUSIONS: The demand for vein for secondary procedures is low. Amputation rates when vein grafts do occlude are half those of PTFE and amputation level is significantly influenced by graft type. We advocate preferential use of vein in above-knee femoropopliteal bypass.

Ruptured abdominal aortic aneurysms: selecting patients for surgery.

OBJECTIVES: Mortality from ruptured abdominal aortic aneurysm (RAAA) remains high. Despite this, withholding surgery on poor-prognosis patients with RAAA may create a difficult dilemma for the surgeon. Hardman et al. identified five independent, preoperative risk factors associated with mortality and proposed a model for preoperative patient selection. The aim of this study was to test the validity of the same model in an independent series of RAAA patients. METHODS: A consecutive series of patients undergoing surgery for RAAA was analysed retrospectively by case-note review. Thirty-day operative mortality and the presence of the five risk factors: age (> 76 years), creatinine (Cr) (> 190 mumol/l), haemoglobin (Hb) (< 9 g/dl), loss of consciousness and electrocardiographic (ECG) evidence of ischaemia were recorded for each patient. RESULTS: Complete data sets existed for 69 patients (mean age: 73 years, range: 38-86 years, male to female ratio: 6:1). Operative mortality was 43%. The cumulative effect of 0, 1 and 2 risk factors on mortality was 18%, 28% and 48%, respectively. All patients with three or more risk factors died (eight patients). CONCLUSIONS: These results lend support to the validity of the model. The potential to avoid surgery in patients with little or no chance of survival would spare unnecessary suffering, reduce operative mortality and enhance use of scarce resources.

Magnetic resonance angiography or IADSA for diagnosis of carotid pseudo occlusion?

Accurate diagnosis of internal carotid artery (ICA) occlusion is essential in the investigation of carotid disease yet may be difficult using Duplex. Traditionally contrast arteriography has been used to confirm the diagnosis despite its cost and potential dangers. Twenty-one patients with 23 ICA occlusions were evaluated by a 3-dimensional time of flight magnetic resonance angiography (MRA) technique. The cervical carotids and circle of Willis were imaged during the MRA examination which lasted 30 minutes. Confirmatory conventional angiography was performed in all patients. Using angiography as the gold standard, all occlusions were correctly diagnosed by MRA and 22 of 23 occlusions correctly diagnosed by Duplex. There was good agreement between MRA and angiography for all 42 ICAs imaged (Kappa statistic 0.83). Diagnosis of internal carotid artery occlusion is critical as it determines the need for operation. In this situation MRA provides a useful non-invasive complement to Duplex. A combination of non-invasive studies may enable arteriography to be rejected with greater confidence in this high risk group.

Pulse-generated run-off versus dependent Doppler ultrasonography for assessment of calf vessel patency.

Pulse-generated run-off (PGR) is an established technique in the assessment of calf vessel patency. Dependent Doppler ultrasonography is proposed as a fast and simple alternative. Twenty-six limbs with severe ischaemia were evaluated by PGR, dependent Doppler examination and intra-arterial digital subtraction angiography (DSA). PGR was performed and scored as previously described. Dependent Doppler ultrasonography was performed after 5 min of foot dependency and scored as for PGR. Angiograms were scored by an independent radiologist, who awarded 2 for a vessel widely patent to the ankle, 1 for a diseased vessel crossing the ankle and 0 if no vessel was visualized. Of 78 calf vessels evaluated, 59 (76 per cent) appeared patent on PGR and dependent Doppler examination but only 33 (42 per cent) appeared patent to the ankle with intra-arterial DSA. There was very good agreement between PGR and dependent Doppler for detection of patent calf vessels (kappa = 0.93). Doppler signals were biphasic in six calf vessels on dependency and in 22 vessels with PGR. PGR and dependent Doppler ultrasonography detected 26 vessels communicating with the pedal arch compared with seven detected angiographically. There was good agreement between PGR and dependent Doppler examination for diagnosis of the most suitable vessel for distal anastomosis (kappa = 0.80). The wide availability and simplicity of dependent Doppler ultrasonography mean that no patient with a critically ischaemic limb should be denied reconstructive surgery on the basis of angiographic findings alone.

Vein quality influences neointimal hyperplasia in an organ culture model of human saphenous vein.

OBJECTIVES: The severity of pre-existing pathological changes in human saphenous vein (HSV) correlates with the development of vein graft stenosis and graft patency. The aim of this study was to investigate the influence of pre-existing intimal hyperplasia on development of the neointima in vitro, using an organ culture model. MATERIALS AND METHODS: Segments of HSV were harvested during coronary artery bypass surgery. Histology was performed on part of the vein; the remainder was maintained in culture. Pre-existing intimal thickness (PIT) in HSV from day 0 and neointimal thickness (NIT) in cultured HSV were measured using computerised image analysis on histological sections. Day 0 and 14 veins were compared with respect to intimal hyperplasia. RESULTS: Twelve pairs of veins were examined. A mean tissue ATP of 297 nmoles/g wet weight for cultured. HSV confirmed cell viability. Mean PIT was 180 microns (CI: 86-274) and mean NIT was 60 microns (CI: 48-72), with a significant correlation between them using the Spearman Rank test (Rs = 0.72; p = 0.008). CONCLUSIONS: Pre-existing vein quality as measured by PIT correlates with the development of neointimal hyperplasia in culture, adding further support to clinical evidence that poor vein quality predisposes to vein graft stenosis due to an inherent susceptibility to intimal hyperplasia.

Hyperhomocysteinaemia is a risk factor for vein graft stenosis.

OBJECTIVES: Many infrainguinal vein graft failures are due to progressive vein graft stenosis (VGS) from intimal hyperplasia. Systemic factors have been implicated in the aetiology of intimal hyperplasia. Hyperhomocysteinaemia (HHCA) is established as an independent risk factor for coronary and peripheral arterial disease. The objective of this study was to examine the influence of HHCA and other serological factors upon the development of VGS. STUDY DESIGN: Thirty-eight patients who had undergone infrainguinal vein bypass were recruited to a case/control study from a graft surveillance program. Nineteen patients with documented VGS were matched against controls without stenosis for age, sex, length of time from surgery, diabetes, smoking history and preoperative symptom score. All patients were recalled for Duplex ultrasound scans, venesection and carbon monoxide estimation which were performed in a blinded fashion. RESULTS: Statistical analysis of all parameters revealed that plasma homocysteine was significantly elevated in patients with VGS (p < 0.3, Wilcoxon rank sum). CONCLUSIONS: These results suggest that HHCA is a previously unidentified risk factor for VGS. Patients with HHCA are susceptible to VGS and preoperative investigation would allow identification of patients at risk.