Avoiding, diagnosing and treating well leg compartment syndrome after pelvic surgery.

BACKGROUND: Patients undergoing prolonged pelvic surgery may develop compartment syndrome of one or both lower limbs in the absence of direct trauma or pre-existing vascular disease (well leg compartment syndrome). This condition may have devastating consequences for postoperative recovery, including loss of life or limb, and irreversible disability. METHODS: These guidelines represent the collaboration of a multidisciplinary group of colorectal, vascular and orthopaedic surgeons, acting on behalf of their specialty associations in the UK and Ireland. A systematic analysis of the available peer-reviewed literature was undertaken to provide an evidence base from which these guidelines were developed. RESULTS: These guidelines encompass the risk factors (both patient- and procedure-related), diagnosis and management of the condition. Key recommendations for the adoption of perioperative strategies to facilitate prevention and effective treatment of well leg compartment syndrome are presented. CONCLUSION: All surgeons who carry out abdominopelvic surgical procedures should be aware of well leg compartment syndrome, and instigate policies within their own institution to reduce the risk of this potentially life-changing complication.

Cost-effectiveness analysis of a randomized clinical trial of early versus deferred endovenous ablation of superficial venous reflux in patients with venous ulceration.

BACKGROUND: Treatment of superficial venous reflux in addition to compression therapy accelerates venous leg ulcer healing and reduces ulcer recurrence. The aim of this study was to evaluate the costs and cost-effectiveness of early versus delayed endovenous treatment of patients with venous leg ulcers. METHODS: This was a within-trial cost-utility analysis with a 1-year time horizon using data from the EVRA (Early Venous Reflux Ablation) trial. The study compared early versus deferred endovenous ablation for superficial venous truncal reflux in patients with a venous leg ulcer. The outcome measure was the cost per quality-adjusted life-year (QALY) over 1 year. Sensitivity analyses were conducted with alternative methods of handling missing data, alternative preference weights for health-related quality of life, and per protocol. RESULTS: After early intervention, the mean(s.e.m.) cost was higher (difference in cost per patient £163(318) (€184(358))) and early intervention was associated with more QALYs at 1 year (mean(s.e.m.) difference 0·041(0·017)). The incremental cost-effectiveness ratio (ICER) was £3976 (€4482) per QALY. There was an 89 per cent probability that early venous intervention is cost-effective at a threshold of £20 000 (€22 546)/QALY. Sensitivity analyses produced similar results, confirming that early treatment of superficial reflux is highly likely to be cost-effective. CONCLUSION: Early treatment of superficial reflux is highly likely to be cost-effective in patients with venous leg ulcers over 1 year. Registration number: ISRCTN02335796 (http://www.isrctn.com).

A combined vascular surgical and clinical genetics approach to diffuse aneurysmal disease.

We report two patients who presented with extensive aneurysmal disease, in association with minimal external physical signs. Patient 1 remained genetically undiagnosed despite multiple structural, biochemical and genetic investigations. He made a good recovery following surgery for popliteal and left axillary artery aneurysms. Patient 2 was diagnosed with vascular type Ehlers-Danlos syndrome, associated with a high degree of tissue and blood vessel fragility, and is being managed conservatively. Early multidisciplinary assessment of such patients facilitates accurate diagnosis and management.

Pseudoaneurysm of the peroneal artery: presentation of Ehlers-Danlos syndrome type IV.

INTRODUCTION: Pseudoaneurysms in deep or unusual sites raise the possibility of an underlying vessel wall disorder. REPORT: A 28-year-old woman presented with pain and swelling of her calf, with no history of trauma. Angiography diagnosed a peroneal artery pseudoaneurysm, which we embolised successfully. Subsequent genetic analysis revealed the COL3A1 mutation, confirming Ehlers-Danlos syndrome type IV. CONCLUSION: To our knowledge, this is the first report of a peroneal artery pseudoaneurysm associated with underlying collagen vascular disease.

Inferior mesenteric artery aneurysm with occlusion of the superior mesenteric artery, coeliac trunk and right renal artery.

Inferior mesenteric artery aneurysms are amongst the rarest of visceral aneurysms. We present here a case associated with occlusion of the superior mesenteric artery, coeliac trunk and right renal artery. Operative treatment was resection of the aneurysm, with end-to-end anastomosis. This is the first description of this condition from the UK, with only nine other reports worldwide. Such pathology may be caused by a "jet disorder" phenomenon, with increased flow through the inferior mesenteric artery due to chronic mesenteric occlusive disease.

Current management of popliteal fossa incompetent superficial venous systems.

OBJECTIVES: Controversy exists regarding the management of varicose veins at the level of the popliteal fossa. This questionnaire reviews the current practice of vascular surgeons. METHODS: A postal questionnaire was sent to 440 consultant surgeon members of the Vascular Society of Great Britain and Ireland. Recipients were asked to indicate their current practice of investigation and management of small saphenous (SSV), gastrocnemius and Giacomini varicosities. RESULTS: We have received 296 (67%) responses to the questionnaire. Duplex scanning is utilized by 275 (93%) for the initial assessment of patients. Preoperatively, 188 (64%) reuse duplex scanning to mark the saphenopopliteal junction (SPJ) site, 53 (18%) mark with hand-held Doppler only and 24 (8%) do not mark the SPJ. At operation, 198 (67%) flush ligate the SPJ and 87 (29%) tie the SSV 2-3 cm from the junction. A total of 101 (34%) usually strip the SSV to various levels. In symptomatic patients, 158 (53%) ligate the SPJ when an incompetent segment of SSV with a competent SPJ exists. One hundred and sixty-nine (57%) disconnect incompetent gastrocnemius veins during SPJ surgery and 172 (58%) regularly look for the Giacomini vein. Routine follow-up after surgery is practised by 172 (58%), most commonly at six weeks. This is mostly (88%) by clinical examination, with 14 (8.1%) using duplex scanning and six (4.7%) using a nurse-run clinic for the follow-up. CONCLUSIONS: This review suggests marked variation in the management of popliteal fossa venous incompetence. There is a clear need for further research to clarify the role of ablation in the management of symptoms and skin changes.

Can preoperative duplex marking of the saphenopopliteal junction be avoided?

OBJECTIVES: Patients undergoing saphenopopliteal junction (SPJ) surgery are currently subjected to two duplex scans. The first is to confirm the reflux, and the second is done preoperatively to accurately mark the SPJ for surgery. The aim of this study was to assess whether the use of hand-held Doppler (HHD) can substitute the second duplex scan. METHODS: Sixty limbs with suspected SPJ reflux were studied. Patients underwent an initial duplex scan. The report detailed the position of SPJ in relation to popliteal crease. Guided by this, a HHD was then used to mark the SPJ. Deviation of the HHD mark from the duplex one of < or =10 mm was considered acceptable for surgical accuracy. RESULTS: HHD accurately localized all 27 patients with SPJ reflux (100% accuracy). The distances between the HHD and duplex points in this group ranged between 0 and 5 mm (median=0). Twenty-five patients had SPJ with no reflux, and 22 of them were accurately localized (88%). The distances between the two points in the latter group ranged between 0 and 16 mm (median=3). CONCLUSION: HHD, guided by the routine duplex scan, can accurately mark SPJ with reflux. A second duplex is not required for marking prior to surgery. This will reduce the workload of the vascular laboratory.

Aortic aneurysm replacement with Dacron graft in a 34 year old man. How long will the graft last?

A unique case of an abdominal aortic aneurysm replacement in a young man of Caribbean descent is presented. The initial working diagnosis was of a mycotic aneurysm, which has recently shown resurgence with intravenous drug abuse. Blood tests and subsequent biopsy ruled that out. There was also a clinical suspicion of a connective tissue abnormality. Histological examination of the aneurysm, skin biopsy, and blood tests also ruled out this possibility. The graft used in this patient was from a new generation of grafts. In the absence of any studies on such grafts, there is the question of long term durability of the graft.

Rational approach to combined carotid and ischaemic heart disease.

BACKGROUND: The management of patients with concomitant coronary and carotid artery disease remains a controversial subject. The aim of this review was to develop a rational plan for the management of such patients based on a review of the literature. METHOD AND RESULTS: A retrospective review was carried out of relevant papers derived from the Medline database from 1964 to 1996. CONCLUSION: The management of patients with concomitant coronary and carotid artery disease has not yet been put to the test in a properly designed and randomized multicentre trial. It is suggested that, until the results of such a trial are available, the rational approach to combined symptomatic disease is combined carotid endarterectomy and coronary artery bypass grafting (CABG). Combined surgery is also appropriate for patients with symptomatic carotid artery disease and significant but asymptomatic cardiac disease. At present there is inadequate evidence to promote carotid endarterectomy for asymptomatic disease in combination with CABG.

The importance of the resection margin in conservative surgery for breast cancer.

Eradication of breast cancer by wide local excision alone is not possible unless the clinical margins of excision exceeds 5 cm or a segmental mastectomy is performed, though recurrences may still occur after a segmental mastectomy. With inadequate excision radiotherapy to the breast is essential, but will not prevent local recurrence. In a prospective trial (1981 to 1990) to assess the value of radiotherapy to the breast when adjuvant therapy was administered, 418 patients treated by wide local excision and adjuvant chemotherapy (tamoxifen if oestrogen receptor-positive and CMF chemotherapy if oestrogen receptor-negative) were randomized to have loco-regional radiotherapy to the breast or not. At a minimum 5-year follow-up, the local recurrence rate in patients receiving radiotherapy was 13% compared to 35% in those not so treated. Local recurrence was strictly related to microscopic clearance in millimetres irrespective of clinical wide local excision, nodal, or menopausal status. Where, histologically, local excision was incomplete and patients received radiotherapy, the local recurrence rate was 17%. The criteria for wide local excision need to be strictly defined and histologically proven if post-operative radiotherapy is to achieve its effective function, that is the prevention of local recurrence. Radiotherapy cannot compensate for inadequate surgery.

Arterial wall changes in type 2 diabetic subjects.

Arterial ultrasonic appearances using high resolution ultrasound were studied in 97 subjects with Type 2 diabetes and age- and sex-matched controls. The intima-media thickness of both common carotid arteries was measured 2 cm proximal to the bifurcation and the presence or absence of plaque on both common and femoral bifurcations was recorded. The mean intima-media thickness in subjects with diabetes was 0.82 +/- 0.22 mm while in the controls 0.66 +/- 0.13 mm (p < 0.001). Multiple regression in diabetic subjects only showed no correlation between age, sex, body mass index, smoking, duration of diabetes, systolic or diastolic blood pressure, cholesterol, HDL, LDL, triglycerides, HbA1 and the common carotid artery intima-media thickness. Type 2 diabetes is associated with increased intima-media thickness which has been found to be a marker of cardiovascular events in the general population.

Measurement of the ultrasonic intima-media complex thickness in normal subjects.

PURPOSE: The evolution of atherosclerosis can be studied before development of symptomatic plaque by evaluating morphologic changes of the intima-media (I-M) complex, seen on high-resolution ultrasonography of the arterial wall. These qualitative changes require large alterations in vessel wall appearance to recognize progression of atherosclerosis. It has been suggested that measurement of the thickness of the I-M complex may be a quantitative and more sensitive method of assessing these early atherosclerotic changes. METHODS: High-resolution ultrasonography has been used to measure the thickness of the I-M complex in 140 symptom-free subjects. RESULTS: The mean thickness of the I-M complex of the common carotid arteries was linearly related to the age (r = 0.77; p < 0.001), pack-years of smoking (r = 0.39; p < 0.05), the systolic blood pressure (r = 0.51, p < 0.01), and to the arterial ultrasound score (r = 0.85). The arterial ultrasound score has previously been shown to correlate with the presence of asymptomatic myocardial ischemia and with the development of cardiovascular symptoms. The mean thickness of the I-M complex in subjects without plaque (in the common carotid or common femoral artery bifurcations) was significantly thinner than in subjects with plaque (p < 0.001). CONCLUSION: The thickness of the I-M complex of the common carotid arteries is a measure of the risk for the development of cardiovascular symptoms in symptom-free individuals.

Noninvasive ultrasonic biopsy: evaluation of early arteriosclerotic lesions progression in normal asymptomatic, hyperlipidemic, and diabetic subjects.

Noninvasive ultrasonic biopsy (UB) is a method of detecting early arteriosclerotic changes by high-resolution ultrasound scanning of the carotid and femoral bifurcation. Six UB classes (scoring 0 to 10) have been identified in 2000 asymptomatic subjects and 600 vascular patients followed up for four years. The incidence of silent coronary ischemia (tested by effort test) and the occurrence of symptomatic events in four years are increased in advanced classes and with increasing UB score. The rate of progression (ROP) in four years to the next UB class has been defined in normal subjects (1.4% in class I, 3.1% in II, 10.7% in III, 17.9% in IV, and 79.2% in class V). In a group of 305 asymptomatic hyperlipidemic subjects and in a group of 269 diabetics the ROP (in four years) was significantly higher. Therefore ultrasonic biopsy is useful to identify subjects at risk of coronary ischemia and cardiovascular events and to follow up noninvasively the progression of arteriosclerosis.

Screening asymptomatic subjects with subclinical arteriosclerotic lesions with arterial ultrasonic biopsy. The P.A.P. study.

Ultrasound Biopsy is a an effective screening method for detecting early, subclinical arteriosclerotic lesions. Carotid and femoral artery wall lesions are important markers of generalized cardiovascular disease. The evaluation of 4 arterial sites (both carotid and femoral arteries) gives a clue of the status of the whole cardiovascular system. In 27.9% of all patients the femoral lesions are present earlier or in a more advanced stage than carotid lesions. Different age groups have a different UB class distribution and score due to the progression with age of the disease. Early arterial lesions and small plaques are important indicators of silent coronary ischemia and cardiovascular events. The method has also an impact on patients' compliance. Subjects with early plaques shown by high resolution ultrasound are more impressed by this finding than by laboratory results.

Evaluation of arteriosclerosis progression with ultrasonic biopsy and intima-media thickness measurements.

Noninvasive ultrasonic biopsy (UB) can be used to classify arteriosclerotic lesions and their progression in the carotid and femoral bifurcation. Six UB classes have been defined. The rate of progression (ROP) to the next UB class in four years has been defined in 1270 normal subjects: it was 1.4% from class I to class II, 3.1% from II to III, 10.7% from III to IV, 17.9% from IV to V and 79.2% from class V to VI. In high risk subjects (HRS)--305 hyperlipidemics, 269 diabetics and 381 hypertensives--the ROP in 4 years was significantly higher considering all classes. This finding was matched by a more significant increase in intima-media thickness (IMT) increase in HRS in comparison with normal subjects. In conclusion UB and IMT measurements can be used to monitor arteriosclerosis progression. HRS have a comparable increase in ROP and IMT in four years indicating rapid progression in comparison with normals. UB appear to be more effective in evaluating progression when plaques and wall irregularities make IMT measurements difficult.

Non-invasive ultrasonic biopsy in the classification of early arterial lesions and in the evaluation of the rate of progression of arteriosclerosis.

The evaluation of early arterial lesions and the follow-up of the progression of arteriosclerotic wall changes is possible with high resolution ultrasound. While dynamic (duplex scanning) data are suitable for the follow-up of advanced stenosis and plaques, the morphological evaluation performed using the technique of non-invasive ultrasonic biopsy may be used to follow-up early lesions and their progression. The data obtained by ultrasonic biopsy are related to the incidence of occult coronary ischemia and to the occurrence of cardiovascular events in 4 years. The rate of progression (ROP) to the next, more advanced UB class can be also evaluated by ultrasonic biopsy. It has been shown that in diabetic and hyperlipidemic subjects the ROP is higher. Also in interventional studies using lipid lowering agents (with a four-year follow-up) a reduction in ROP in treated asymptomatic hyperlipidemic subjects in comparison with controls has been documented. The combination of dynamic data and morphological data gives us a complete evaluation of the vascular system both for the assessment of single individuals and for large population studies.

Impact of duplex scanning on vascular surgical practice.

This review outlines the development of duplex scanning over the past 15 years and its value not only in vascular medicine and surgery but also in the field of transplantation and obstetrics. It is now the first line of investigation of patients with symptomatic carotid bifurcation disease and those with clinically suspected acute deep venous thrombosis. It is also an established method of femoropopliteal and femorodistal arterial graft surveillance, determination of the extent and cause of chronic venous insufficiency, detection of placental insufficiency and portasystemic shunt patency, early transplant monitoring, as well as of detecting an arterial stenosis suitable for angioplasty. In addition, it is developing into the method of choice for the initial investigation of patients with suspected mesenteric or renal artery stenosis. The accuracy of duplex scanning, avoiding further unnecessary invasive and expensive diagnostic procedures, makes it one of the most cost-effective investigations ever introduced into clinical practice. Also, when used as a screening technique in arterial and venous disease, it selects those patients who need more invasive procedures such as angiography. This helps to reduce waiting lists of patients requiring investigation, and better directs limited resources to treatment rather than investigation.