Contemporary results for open repair of suprarenal and type IV thoracoabdominal aortic aneurysms.

BACKGROUND: Endovascular and hybrid procedures are not yet widely established in the management of type IV thoracoabdominal aortic aneurysm (TAAA). Open surgery remains the treatment of choice until the long-term outcomes of these novel techniques are known. METHODS: This study reviewed a 10-year experience of open repair of non-ruptured type IV and suprarenal TAAA. All procedures were performed using a totally abdominal approach with supracoeliac clamping of the aorta. RESULTS: There were 53 patients (31 men; 58 per cent) of median age 69 (range 54-82) years. Forty-four patients had a type IV TAAA and nine a suprarenal aneurysm. Three patients (6 per cent) died within 30 days and the 12-month mortality rate for patients followed for at least 1 year was 6 per cent (three of 49). Ten patients (19 per cent) had a cardiac complication, 20 (38 percent) a respiratory complication, three (6 percent) required early reoperation, and one patient (2 percent) developed permanent paraplegia. There was one late death resulting from an aneurysm-related complication. CONCLUSION: Open repair of suprarenal aneurysms and type IV TAAA may be undertaken using a totally abdominal approach with acceptable levels of morbidity and mortality.

Regional versus general anaesthesia for carotid endarterectomy: impact of change in practice.

BACKGROUND: Local anaesthesia (LA) for carotid endarterectomy (CEA) may offer advantages over general anaesthesia (GA). AIM: Our aim was to compare outcome from CEA before and after changing our anaesthetic technique from GA to LA. METHODS: Sequential patients who underwent CEA between January 1997 and December 2001 were identified from a prospectively collected database. GA was used during the first two years of this period and LA was used exclusively over the last three years. Differences in the incidence of intraoperative shunting, perioperative stroke and transient ischaemic attack (TIA), cranial nerve injury, neck haematoma, perioperative death and duration of hospital stay were assessed. RESULTS: Three hundred and seventy one CEAs were carried out in 363 patients, 179 under GA and 192 under LA. Indications were TIAs (140), stroke with recovery (134), amaurosis fugax (85) and asymptomatic high-grade stenosis (12). Intraoperative shunting was used in 66 (37%) GA operations and 36 (18.8%) LA operations (p<0.01). There were nine strokes and four transient neurological events; 10 (5.5%) patients developed such problems with GA and three (1.6%) with LA (p<0.05). There were four deaths, three (1.7%) after GA and one (0.5%) after LA (p=NS). Duration of hospital stay was less in the LA group at a median (range) of three days (2-10) compared with 4.5 (3-14) days in the GA group (p<0.001). CONCLUSION: Employing LA rather than GA for CEA has been associated with a reduction in intraoperative shunting and perioperative stroke, and the duration of hospital stay. LA appears to offer clinical and possible cost advantages over GA.

Changing pattern of scrotal exploration for testicular torsion.

A total of 201 urgent scrotal explorations for unilateral painful testis was performed over a six-year period. Seventy-two (36%) testicular torsions were identified. Fifty-seven (79%) testes were salvaged and fifteen (21%) orchiectomies were done. Although the annual number of scrotal explorations increased over the years of study, no benefit in terms of increased testicular salvage could be identified.

Ultrasonic doppler spectral broadening in the diagnosis of internal carotid artery stenosis.

In a clinical study, 78 carotid bifurcations were examined by pulsed Doppler ultrasonography and X-ray arteriography. Maximum Doppler frequencies greater than or equal to 3 kHz diagnosed stenoses of greater than or equal to 25% diameter reduction with a sensitivity of 73% and specificity of 79%. A quantitative analysis of the degree of spectral broadening was obtained from the ratio of the maximum to mean frequency at peak systole and improved the sensitivity and specificity to 90% and 98% respectively. All vessels greater than 40% stenosis were correctly classified as stenosed and all less than 20% stenosis were classified as normal.

Arterial embolectomy in the leg: results in a referral hospital.

A review of 66 patients undergoing femoral embolectomy showed that 38 (58%) obtained a good final outcome (discharge from hospital with viable limb) while 28 (42%) died or required amputation prior to discharge. The major association with poor final outcome was pre-operative life-threatening cardiac disease which occurred in 17 (61%) of those patients who later died or underwent amputation and in six (16%) of those who were discharged with viable limbs (p less than 0.001). Age, sex, source of embolus, duration of ischaemia and pre-existing vascular disease had little effect on final outcome. Surgical dissatisfaction, at the time of operation, with the result of attempted revascularisation was of major prognostic significance in terms of future amputation or death.

Arterial assessment before carotid endarterectomy: current practice in Great Britain and Ireland.

A survey of the management of patients with putative carotid artery disease by 245 vascular and neurosurgeons in Great Britain and Ireland was conducted with a 96 per cent response. Ninety-six (41%) surgeons performed at least one carotid endarterectomy in 1984 and a total of 1374 such operations were carried out in that year. Of the 40 surgeons who performed more than ten operations in 1984, 95 per cent generally employed a screening technique which was less invasive than conventional angiography in their management. Techniques based on ultrasonography were more popular than those based on digital subtraction angiography (DSA) in this respect. If carotid endarterectomy were to be undertaken, 63 per cent of surgeons required pre-operative conventional angiograms. Of the 38 per cent who did not routinely use conventional angiography, all but one used digital subtraction angiography. Ultrasonography and DSA have had a significant impact on the management of carotid artery disease in Great Britain and Ireland and their individual places in such management are becoming clear.

Radiographic assessment of the extracranial internal carotid artery.

The accuracy of new (non-invasive) techniques of carotid artery assessment is classically established by comparing the results of the method under study with those of conventional contrast angiography. It is, therefore, important to establish the reproducibility of data acquired from contrast angiograms. Categories of carotid lesion must be chosen such that good reproducibility is likely both on an inter and intra-observer basis. This paper suggests that the smallest useful number of categories be used. It a two category discriminating system (less than 25% and greater than or equal to 25% stenosis), inter-observer agreement was found to be 95% and intra-observer agreement 96%. The principal observer variation occurred at the 0% and greater than 0% level of discrimination and this should be avoided in future studies comparing new arterial assessment techniques with conventional angiography.

Radiographic anatomy of the extracranial carotid artery.

Only 55% of common carotid arteries bifurcate in the neck at the classically described level of C3 vertebra or C3/4 interspace. Others bifurcate as high as C2/3 interspace or as low as C5/6. Eighty-five percent of bifurcations occur at the same height as that on the contralateral side. Even if asymmetry occurs, it is not greater in magnitude than the height of one cervical vertebra. Atheroma does not appear to be associated with any particular bifurcation position. Abnormally curved or kinked morphology of the extracranial internal carotid occurs in 6% of angiograms. This feature also has no specific association with atheroma.

Amyloid disease: association with failure of arterial reconstruction.

Amyloidosis may accompany many chronic diseases and in particular occurs as a complication of myelomatosis in 10% of cases. This paper reports the effects of amyloid in major arteries of the leg, and describes attempts to treat this occlusive disease using vascular grafts. Such disease may be rapidly progressive and its presence may indicate a poor outlook after vascular surgery. Arterial biopsy at the time of operation in patients with diseases associated with amyloidosis may be useful in assessing prognosis.

Antiplatelet and anticoagulant therapy to prevent bypass graft thrombosis in patients with lower extremity arterial occlusive disease.

The incidence of graft failure for above knee femoropopliteal grafts is described by the European Consensus Document on Critical Limb Ischaemia. It occurs in approximately 15% of patients when vein is used for the grafting procedure and in 20% of patients when PTFA (polytetrafluoroethylene) or other prosthetic material is used. Femorodistal grafts have a much poorer outcome with 45% and 75% failure rates for vein and prosthetic grafts, respectively. Prevention of primary graft failure and thus the need for surgical reintervention is of major clinical and economic importance. Early failure, occurring within one month of operation, is usually due to technical error such as poor patient selection or operative technique. Approximately 10% of graft failures will fall into this time period. When grafts thrombose after two years, progression of native atherosclerosis either proximally or distally is the usual cause. This accounts for 2-3% of all graft failures each year. The most common time for grafts to fail is between one month and two years (80% of all failures) and this is the same period in which graft stenoses are now known to develop. There are few evidence-based recommendations for the use of pharmacological agents in maintaining graft patency following peripheral vascular surgery. This article reviews the evidence for or against the use of anticoagulant and antiplatelet therapy for the prevention of bypass graft thrombosis in patients with peripheral arterial occlusive disease.

Pressure contour analysis in the assessment of arterial stenosis.

Femoral artery pressure contour can be measured directly by percutaneous needle puncture and may be a useful indicator of proximal vessel stenosis. Pressure waveform in 53 limbs was compared with radiological appearance of the aorto-iliac segment. Forty-one limbs were graded angiographically as normal and 12 as stenosed. Pressure contour was studied at rest and after intra-arterial injection of papaverine. The following parameters were examined: 1. systolic pressure at rest 2. systolic pressure after papaverine 3. per cent reduction of systolic pressure after papaverine 4. pulse pressure at rest 5. pulse pressure after papaverine 6. per cent reduction in pulse pressure after papaverine 7. maximal gradient (dp/dt) at rest 8. maximal gradient after papaverine: p less than 0.001 (Figure 5b) 9. (formula; see text) A significant difference between the angiographic normal and stenotic groups was found in the values of all parameters. p less than 0.001 for 1 to 8 inclusive; p less than 0.05 for 9. Good discrimination between groups was achieved only by 3, 6 and 8. Three produced the best discrimination: systolic pressure reduction after papaverine greater than or equal to 14 per cent indicating stenosis (1 in 12 false negative) and less than 14 per cent indicating no stenosis (no false positive).

Pulsed Doppler imaging and spectrum analysis for detection of carotid artery disease.

One hundred carotid arteries in 53 patients suffering from transient cerebral ischaemia or amaurosis fugax have been studied prospectively. Internal carotid arteries were assessed by a six-channel pulsed Doppler imaging system combined with Doppler spectrum analysis and the findings compared with those obtained by X-ray contrast arteriography. Stenosis (greater than 25% diameter reduction) was correctly diagnosed by ultrasonography with a sensitivity of 93% and a specificity of 96%. Occlusion was correctly diagnosed with a sensitivity of 92% and a specificity of 97%. The ability to recognize arterial stenosis and occlusion with this noninvasive system suggests that it has a major part to play in screening patients with suspected carotid artery disease.

A comparison of reports from referees chosen by authors or journal editors in the peer review process.

The aim was to analyse the peer review process by comparing reports produced by referees selected by journal editors, with those of referees selected by the authors of a scientific manuscript. Some 104 consecutive papers from the UK submitted to the British Journal of Surgery (BJS) were included. Of these, 102 were reviewed blind both by referees chosen by the journal editors, and referees chosen by the paper's principal author. Manuscripts were marked using a standard sheet for four basic aspects: originality, clinical/scientific importance, clarity and analysis; a final overall recommendation about possible publication was given. The time taken and the number of completed referee reports were similar in each group. Referees chosen by the BJS editors were more critical (scored higher) of the submitted articles. Mean scores for all domains were higher than for authors' referees, significantly for scientific importance (p = 0.009) and decision to publish (p = 0.029). In conclusion, reports produced by referees selected by BJS editors were more critical than those chosen by authors of the papers. Authors might argue that this reduced their chance of publication but constructive criticism might improve the final article and assist editors to make decisions about acceptance or rejection.

Above-knee femoropopliteal bypass grafts and the consequences of graft failure.

In all, 290 femoral to above-knee popliteal artery bypasses were performed between January 1983 and September 1991. PTFE grafts were used in 113 cases (39%) and vein grafts in 177 (61%) (reversed in 146 cases and in situ in 31). Patients were followed up for a median time of 20 months. The 2-, 4- and 6-year patency rates for vein and PTFE grafts were 70%, 62% and 57%, respectively, compared with 58%, 46% and 41% (no statistical difference in survival curves, P = 0.2). The 2-, 4- and 6-year limb salvage rates were 82%, 78% and 62% compared with 75%, 64% and 58% (no statistical difference in survival curves, P = 0.6). A total of 99 grafts occluded during follow-up (45 PTFE and 54 vein grafts). Major amputation was required in 63 limbs; below-knee in 37 limbs (59%), and above-knee in 26 limbs (41%). There was no statistical difference in the amputation level with respect to the graft type. Final healing at the below-knee level was achieved in 23 of 35 (66%) failed vein grafts and in 14 of 28 (50%) failed PTFE grafts.

Chlorhexidine in methanol for the preoperative cleansing of surgeons' hands: a clinical trial.

A clinical trial has shown that a technique of preoperative hand disinfection using a methanolic solution of chlorhexidine is faster, cheaper and more acceptable to users than the conventional aqueous detergent chlorhexidine preoperative scrub regime. The wound infection rate in general surgical patients was not influenced by the method used.

Pulsed Doppler imaging for carotid artery disease.

Ultrasonic imaging using a six-channel pulsed Doppler system combined with Doppler spectral analysis of 65 carotid bifurcations has been studied in a prospective clinical trial. The results were compared with X-ray contrast angiography. An overall sensitivity in excess of 90 per cent was achieved using the ultrasound technique, with a specificity of 89 per cent in the detection of significant stenosis or occlusion of the internal carotid artery. The ability to recognise significant arterial stenosis with a non-invasive system suggests that it has a major part to play in screening patients with suspected carotid artery disease.