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.

Trends and outcomes of non-traumatic major lower extremity amputations in an Irish tertiary referral hospital.

OBJECTIVES: Data on vascular patients following amputation in Ireland is lacking, limiting capability to plan services. This paper seeks to benchmark survival and rehabilitation outcomes among vascular patients in Ireland following lower extremity amputation (LEA), and compare subgroups of those undergoing transfemoral (TFA) or transtibial amputation (TTA). METHODS: A review was conducted of all patients who underwent non-traumatic TFA or TTA from 2000 to 2009 in a tertiary vascular surgery centre. Demographics, surgical data, perioperative outcomes, medium-term functional outcomes, and survival were assessed. RESULTS: One hundred and seventy-two patients (2:1 male: female) underwent 192 non-traumatic LEAs. Median age for TFA was 75 years and TTA 67 (p = 0.002). A percentage of 36.5% had undergone prior attempts at surgical revascularization, 25% had undergone prior distal amputation or debridement. Thirty-three (17%) required stump revision. Twenty-three (13.2%) died in hospital. Median survival for those who died in hospital was 17 days (0-367), versus 17 months (2-106) for those who survived to discharge. CONCLUSION: LEA for vascular pathology has significant morbidity and mortality, with long in-patient stays and short median survival; there is need to focus on improving quality of life in postoperative pathways.

Aorto-enteric fistula: changing management strategies.

BACKGROUND: Traditionally treatment of aorto-enteric fistulae involved placement of an extra-anatomic bypass and graft excision. This is associated with limb loss (10-40%) and high mortality (10-70%). More recently in situ revascularisation has been advocated. AIMS: To examine our experience with the changing management of aorto-enteric fistulae over a 22-year period. METHODS: Demographic, clinical, operative and pathological data were recorded retrospectively. RESULTS: Twenty-one patients were included. Seven had primary fistulae. Six died prior to intervention. Five had an extra-anatomical bypass (60% mortality, 40% limb loss), four had in-situ revascularisation (25% mortality), four had a primary repair (25% mortality) and two had insertion of a tube graft (primary fistulae). The overall survival rate was 38%. The postoperative survival rate was 6o%. CONCLUSION: Techniques for operative management continue to evolve. The current trend is towards a local surgical approach with prolonged and intensive postoperative antimicrobial therapy. In our experience this approach has yielded acceptable outcomes.

The impact of the establishment of a surgical high dependency unit on management of abdominal aortic aneurysm.

BACKGROUND: Our ability to maintain satisfactory levels of outcome after elective abdominal aortic aneurysm (AAA) surgery is increasingly strained by rising levels of co-morbidity in the presenting population. In this study we present a comparative outcome analysis of patients undergoing elective AAA surgery 18 months before and after the establishment of a surgical high dependency unit (HDU). METHODS: The preoperative status (ASA and POSSUM scores), operative factors and postoperative outcomes as well as duration of stay were calculated for 104 patients undergoing elective AAA repair (57 prior to the HDU opening and 47 patients afterwards). RESULTS: Patients undergoing surgery in the latter period had significantly higher ASA (2.5 +/- 0.06 versus 2.7 +/- 0.7; p = 0.007), overall POSSUM (33.2 +/- 0.5 versus 35.5 +/- 0.8; p = 0.02) and physiological POSSUM (16.3 +/- 0.3 versus 15.5 +/- 0.2; p = 0.048) scores than those operated on prior to establishment of the HDU (data are mean +/- SEM; 2-tailed p-score). The two groups had similar total lengths of hospital stay (518 versus 534 days). However, following establishment of the HDU patients occupied fewer ICU bed days (110 versus 181). This resulted in a saving of Euro 50,750. CONCLUSION: The efficiency and quality of care following elective AAA surgery can be improved by provision of HDU step-down facilities without significantly increased expenditure.

Venous thromboembolism prophylaxis guideline compliance: a pilot study of augmented medication charts.

INTRODUCTION: Venous thromboembolism (VTE) is a common complication of hospital admission. The incidence of hospital-acquired deep vein thrombosis is approximately 10-40% amongst medical and general surgical patients without prophylaxis. Pulmonary embolism accounts for 5-10% of deaths in hospitalised patients, making hospital-acquired VTE the most common preventable cause of in-hospital death. Studies suggest that prophylactic measures are widely under- and inappropriately used. AIMS: We hypothesised that the introduction of a medication chart with a dedicated VTE prophylaxis section would improve compliance with local guidelines. METHODS: Trial medication charts were piloted over a 4-week period in one surgical and two medical wards. Data on compliance with hospital guidelines were collected before and after introduction using a detailed chart review. The difference in prescribing compliance was assessed with the Chi-squared test. RESULTS: 70 patients were assessed before and 38 after the introduction of the new charts. Initially, only 58.6% (n = 41) of patients' prescriptions were in compliance with local guidelines. In 28.6% (n = 20) of patients, VTE prophylaxis was needed and not prescribed. 7.1% (n = 5) of patients were prescribed an inappropriately low dose of low molecular weight heparin (LMWH) prophylaxis. 2.9% (n = 2) of patients were prescribed inappropriately high dose of LMWH prophylaxis. After introduction of the new medication chart, compliance with guidelines rose to 71% (n = 27, p = 0.09). CONCLUSION: Compliance with VTE guidelines is inadequate. Medication charts with specific sections on VTE assessment and prophylaxis may increase compliance with guidelines.

Metabolic studies following intrahepatic autotransplantation of pancreatic islet grafts.

A patient with chronic pancreatitis underwent 95% pancreatectomy and islet autotransplantation. The pancreatic tissue was prepared by mincing and collagenase digestion, and then embolized into the liver via the portal vein. The patient has been followed with metabolic studies for 1 year. Fasting normoglycemia returned 3 weeks following operation. Intravenous glucose tolerance tests revealed K values that were similar before operation (1.06), and 3 weeks (0.96) and 4 months (1.09) after operation. Four months after islet transplantation, peripheral, portal, and hepatic vein insulin levels were determined simultaneously following an infusion of glucose (0.25 gm/kg) into the portal vein. During a 10-minute interval, right hepatic vein insulin increased fourfold, left hepatic vein insulin increased twofold, and peripheral vein insulin doubled. During this time portal vein insulin remained constant. In addition, significant levels of pancreatic glucagon were present in both hepatic veins, but were undetectable in the portal vein. At 6 months the patient became hyperglycemic and subsequently has required insulin therapy. Restudy at 10 months following islet transplantation revealed a marked drop in K value (0.34), and no evidence of graft function in the liver. These studies represent convincing evidence of transplanted intrahepatic islet cell function for a 6-month period following operation. The grafts for unknown reasons ceased to function at 6 months.

Selective nonoperative management of contained intrathoracic esophageal disruptions.

Eight patients with intrathoracic esophageal disruptions were managed nonoperatively and without pleural drainage. Criteria for nonoperative treatment included the following: disruption contained in the mediastinum or between the mediastinum and visceral lung pleura; drainage of the cavity back into the esophagus; minimal symptoms; and minimal signs of clinical sepsis. Cause of the esophageal perforation was pneumostatic dilatation (1 patient), vomiting (2), and a leak following esophageal operation (5). Antibiotics were administered intravenously to all patients; hyperalimentation was accomplished intravenously in 5, and nasogastric suction was used in only 1. The cavities contracted and the esophageal leaks sealed in all instances. Time before oral intake was resumed ranged from 7 to 38 days (average, 18 days). Days until discharge ranged from 15 to 52 days (average, 28 days).

Hepatobiliary complications of ulcerative colitis.

The records of 202 patients with chronic ulcerative colitis seen over a 12 year period were reviewed. Over one half (55 percent) were found to have liver function test abnormalities. These abnormalities correlated with the extent and severity of ulcerative colitis but not with the duration of the disease. Eight patients (4 percent) developed cirrhosis and four required portasystemic decompression for bleeding varices. Four patients (2 percent) developed biliary tract complications. Two patients were diagnosed as having sclerosing cholangitis, and two patients developed carcinoma of the extrahepatic biliary tree. Three of these four patients had whole colon involvement, but all four had mild clinical disease. It is concluded that the hepatobiliary complications of ulcerative colitis are the most frequent and serious extracolonic manifestations of the disease.

Current role of intravenous cholangiography.

One hundred consecutive intravenous cholangiograms were reviewed. In terms of bile duct and gallbladder visualization, 20 were of excellent quality, 40 were of adequate quality, and 40 were of poor quality or did not visualize. In retrospect, 12 of the studies were originally misinterpreted. Among the 29 patients who were eventually proven to have biliary tract disease, intravenous cholangiography was helpful in making the diagnosis in only 17 (59 percent). In 20 patients the study was performed to establish or rule out a diagnosis of acute cholecystitis; the test was helpful in only 9 (45 percent). It is concluded that intravenous cholangiography frequently results in marginal visualization that is subject to interpretive error. With the current variety of available tests that are able to visualize the biliary tree with a high degree of resolution, intravenous cholangiography has become a diagnostic anachronism.

Pancreatic islet transplantation in dogs. Critical factors in technique.

Total pancreatectomy and intrasplenic autotransplantation of islet tissue was carried out in dogs. The resected pancreas was prepared by the partial islet isolation technique of gland distention, mincing and collagenase digestion. The influence of variations in technique was studied. Using otherwise identical methods, five collagenase lots were compared. Three lots were effective, resulting in successful transplants in 23 of 26 dogs. Two ineffective lots produced no successes in six dogs (p < 0.001). When minced particle size was varied, particles which would pass freely through a 16 gauge needle resulted in no successes in six dogs. With a larger particle size that would pass freely only through a 15 gauge needle, 15 of 15 transplants were successful (p < 0.001). When tissue was minced by hand, 8 of 11 transplants were successful, compared with 15 of 15 when mechanical mincing was used. With variation in collagenase concentration, success occurred in four of six using 300 units of collagenase/ml of minced tissue, in four of six using 600 units and three of six using 1,200 units. It is concluded that minced particle size and collagenase lot are critical variables in this technique of islet transplantation. Mincing method and concentration of collagenase do not appear to be important variables.

Pancreatic islet autotransplantation: results in dogs with chronic duct ligation.

The influence of pancreatic acinar cell atrophy and fibrosis on islet tissue autotransplantation was studied in dogs. Thirty-nine dogs underwent pancreatic duct ligation. After 6 weeks marked acinar cell atrophy and fibrosis developed, similar to that in human chronic pancreatitis. Intravenous glucose tolerance testing revealed only a minor decrease in K value (percent/min decline in plasma glucose) from 2.9 +/- 0.2 to 2.4 +/- 0.1 during the 6 weeks. In a control group of normal dogs, 23 of 26 transplants were successful. In a group of 12 duct-ligated dogs, only 1 of 12 transplants was successful with identical techniques (p less than 0.001). Variations in technique to increase or decrease tissue dispersal did not improve the results in other groups (two successes in 27 dogs). New techniques are required if pancreatic islet transplantation is to be consistently effective in the presence of chronic inflammatory disease of the pancreas.

Inferior mesenteric artery aneurysm.

This case reports a very large inferior mesenteric artery aneurysm and highlights the importance of proper preoperative arteriography in the patients work-up. In addition the case demonstrates an anomalous arterial supply to the gastrointestinal tract from a dilated inferior mesenteric artery which due to occlusion of the superior mesenteric artery and coeliac axis may have been instrumental in the development of this aneurysm.

Is compliance mismatch the major cause of anastomotic arterial aneurysms? Analysis of 42 cases.

In 1,348 anastomoses carried out prior to 1976 at St. Laurence's Hospital, Dublin, 36 anastomotic aneurysms developed for an incidence of 2.7%. Six further anastomotic aneurysms occurred following repair of anastomotic false aneurysms. Suture material failure, infection or lymphatic leakage were not associated with aneurysm formation. Twenty three aneurysms occurred in eight hundred and sixty Dacron to artery anastomoses while 6 occurred in 420 vein to artery anastomoses. Anastomotic false aneurysms were found only with the Dacron to artery anastomoses. Only 9 of 590 anastomoses performed for abdominal aortic aneurysm developed false aneurysms while 14 occurred in 270 for occlusive atherosclerosis. We have concluded that compliance mismatch producing anastomotic shear stress damages the arterial wall. This structural impairment permits tearing out of sutures from the vessel wall. The process is facilitated by prior loss of structural integrity of the vessel wall.

An anaesthetic pre-operative assessment clinic reduces pre-operative inpatient stay in patients requiring major vascular surgery.

BACKGROUND: Patients undergoing major vascular surgery (MVS) require extensive anaesthetic assessment. This can require extended pre-operative stays. AIMS: We investigated whether a newly established anaesthetic pre-operative assessment clinic (PAC) would reduce the pre-operative inpatient stay, avoid unnecessary investigations and facilitate day before surgery (DBS) admissions for patients undergoing MVS. PATIENT AND METHODS: One year following and preceding the establishment of the PAC the records of patients undergoing open or endovascular aortic aneurysm repair, carotid endarterectomy and infra-inguinal bypass were reviewed to measure pre-operative length of stay (LoS). RESULTS: Pre-operative LoS was significantly reduced in the study period (1.85 vs. 4.2 days, respectively, P < 0.0001). Only 12 out of 61 patients in 2007 were admitted on the DBS and this increased to 33 out of 63 patients (P = 0.0002). No procedure was cancelled for medical reasons. CONCLUSION: The PAC has facilitated accurate outpatient anaesthetic assessment for patients requiring MVS. The pre-operative in-patient stay has been significantly reduced.