A Rescue Technique for Intraoperative Proximal Migration of a Nellix Stent During Endovascular Aneurysm Sealing.

PURPOSE: To describe a technique to rescue intraoperative migration of 1 of the 2 Nellix stents during endovascular sealing of abdominal aortic aneurysms (EVAS). TECHNIQUE: The technique requires advancement and inflation of a 10-mm angioplasty balloon into the inlet of the migrated stent via an upper limb approach. Inflation of the balloon allows completion of EVAS without risking the contralateral endobag occluding the inlet of the migrated stent. CONCLUSION: This technique allows safe completion of EVAS without compromising stent patency or aneurysm seal and should be considered when intraoperative migration of a Nellix stent occurs despite appropriate precautions.

Causes of successful medico-legal claims following amputation.

INTRODUCTION: The causes of successful medico-legal claims following amputation were reviewed. METHODS: A retrospective analysis of claims handled by the National Health Service Litigation Authority, from 2005 to August 2010, was performed. Under the Freedom of Information Act, the National Health Service Litigation Authority provided limited details on closed claims, settled with damages, following a search of their database with the term "amputation." No demographic data were provided. RESULTS: During this period, 174 claims were settled by the National Health Service Litigation Authority, who paid out more than £36.3 million. The causes of the claims were the need for a lower limb amputation due to a delay in the diagnosis and or treatment of arterial ischaemia (56), an iatrogenic injury (15), the development of preventable pressure sores (15), the delay and or failure to diagnose a limb malignancy (6) and the delay in the management of an infected pseudo-aneurysm (1). Complications following orthopaedic surgery resulted in 25 successful claims as did the delayed diagnosis or mismanagement of 10 lower limb fractures. Additional claims followed the amputation of the wrong toe (1), a retained foreign body (2), an unnecessary amputation (4), inadequate consent (4), failure to provide thrombo-prophylaxis following amputation resulting in death (2) and a diathermy burn injury during an amputation (1). Delay in the diagnosis of and/or failure to manage an injury or infection resulted in 21 upper limb amputations. There was insufficient information provided in the remaining 11 claims to determine how the claim related to an amputation procedure. The largest single payout for damages (£1.9 million) resulted from the failure to diagnose and treat a femoral artery injury following a road traffic accident leading to an eventual below knee amputation. CONCLUSION: Delays in the diagnosis and or treatment of arterial ischaemia were the commonest reasons for a settled claim. Lessons can be learnt from potentially preventable cases that can be incorporated in medical education and training programs with the aim of reducing both amputation rates and litigation costs.

Medico-legal claims following amputations in the UK and Ireland.

The causes and outcomes of medico-legal claims following amputation were evaluated. A retrospective analysis of the experience of a consultant surgeon acting as an expert witness within the United Kingdom and Ireland (1990-2010). There were 154 claims referred for an opinion of which 53 related to female patients. The median age was 67 (range, 20-101) years. Forty nine (32%) of the patients were known diabetics. Seventy-eight (51%) of the claims actually arose following a medically expected amputation, i.e. an amputation that was not preventable or due to negligence. The other common causes of claims were a delay in the diagnosis and or treatment of arterial ischaemia (34%), and following iatrogenic injuries (5%). Eleven of the claims are still ongoing, 3 went to trial, 52 (34%) were settled out of court and 83 (54%) were discontinued after the claimants were advised that they were unlikely to win their case. Disclosed settlement amounts are reported. Delays in the diagnosis and or treatment of arterial ischaemia were the commonest reasons that a claimant was successful. Half of claims did not proceed but were not without financial and psychological costs.

Deficiencies persist in the experience of UK vascular trainees: a survey of Rouleaux Club members.

AIMS: To evaluate the training experience of the current United Kingdom (UK) vascular trainees. METHODS: A Web-based questionnaire was administered to 217 members of the Rouleaux Club, which represents UK vascular and endovascular trainees, between May and June 2011. RESULTS: A total of 153 trainees (71% response rate) completed the survey; 52% were in posts that do not offer endovascular training, 88% performed <10 peripheral angiograms, and 67% performed part or all of <10 endovascular aneurysm repairs in the last year. Half had no access to formal ultrasound training; 85% believe that vascular access will play a role in their future practice, but 49% performed no vascular access procedures in the past year. No experience of endovenous laser, radiofrequency ablation, or foam sclerotherapy was reported by 33%, 49%, and 46%, respectively. CONCLUSIONS: Trainee experience is insufficient for a modern specialist practice. Separate specialty training in the United Kingdom must address these deficiencies.

Medicolegal claims following laparoscopic cholecystectomy in the UK and Ireland.

INTRODUCTION: The causes and outcomes of medicolegal claims following laparoscopic cholecystectomy were evaluated. SUBJECTS AND METHODS: A retrospective analysis of the experience of a consultant surgeon acting as an expert witness within the UK and Ireland (1990-2007). RESULTS: A total of 151 claims were referred for an opinion. Sixty-three related to bile duct injuries and four followed major vascular injury. Bowel injury resulted in 17 claims. A postoperative biliary leak not associated with a bile duct injury was responsible for 25 claims. Other reasons for claims included spilled gallstones, port-site herniae, haemorrhage and other recognised complications associated with laparoscopic cholecystectomy. Twelve of the claims are on-going, two went to trial, 79 (52%) were settled out of court and 58 (38%) were discontinued after the claimants were advised that they were unlikely to win their case. Disclosed settlement amounts are reported. CONCLUSIONS: Bile duct and major vascular injuries are almost indefensible. The delay in diagnosis and (mis)management of other recognised complications following laparoscopic cholecystectomy have also led to a significant number of successful medicolegal claims.

www.Accurate information for varicose vein patients.com?

INTRODUCTION: The aim of this study was to review the information available to the public regarding the treatment of varicose veins on dedicated UK-based websites. PATIENTS AND METHODS: Websites were identified by using the Google search engine. All identified websites were examined, noting the range of treatments explained and their stated potential complications. Website ownership was also recorded. RESULTS: A total of 49 websites were identified, belonging to individual physicians (21), private clinics or groups (15), national institutions (4) and device/drug manufacturers (4). Five websites were simply redirecting portals and, hence, were excluded from further analysis. Treatment methods discussed were conventional surgery (32), endovenous laser [EVLA] and/or radiofrequency ablation [RFA] (31), and ultrasound-guided foam sclerotherapy [UGFS] (27). Only 19 websites (43%) discussed all treatment methods. Complications mentioned following surgery were: cutaneous nerve damage (56%), recurrence (56%), infection (53%), bleeding (41%) and venous thrombo-embolism (38%). Complications following EVLA/RFA were: cutaneous nerve damage (42%), recurrence (42%), venous thrombo-embolism (39%) and burns (35%). Complications following UGFS were: pigmentation (59%), venous thrombo-embolism (48%), ulceration (41%), recurrence (41%), allergy (26%) and visual disturbance (26%). CONCLUSIONS: Over 50% of the websites examined did not mention all the management methods now available for varicose veins. More importantly, the majority of the websites did not warn of the common complications of intervention. Currently, information on the Internet cannot be relied upon to supplement informed consent and may actually generate unrealistic patient expectations.

Fenestrated stent-graft repair: which stent should be used to secure target vessel fenestrations?

PURPOSE: To investigate in an in vitro model the ability of different covered and uncovered stents to resist displacement/migration of a fenestrated stent-graft. METHODS: Three different types (2 covered, 1 bare) of commonly used 7-mm balloon-expandable stainless steel stents (Jostent, Advanta V12, and Palmaz Genesis) were investigated in a testing rig consisting of 2 overlapping tubes with 2 sets of 7-mm holes representing bilateral renal artery fenestrations and ostia. The rig was attached to a tensile tester via pneumatic clamps. The stents were deployed without flaring to 7 mm through the overlapping holes. The rig was moved apart at a constant rate of 12 mm/min up to a maximum displacement of 6 mm; force versus displacement values were recorded while stent deformation was observed. Tests were repeated at least 6 times for each stent type at room temperature. The median force required to cause a 25%, 50%, or 75% reduction in cross-sectional area of the bilateral "renal artery" stents was determined. RESULTS: The median force (interquartile range) required to cause a 50% reduction in cross-sectional area of identical bilateral "renal artery" stents securing fenestrations was 25.1 N (8.1) for a covered Jostent, 9.3 N (0.9) for a covered Advanta V12 stent, and 7.5 N (0.7) for a bare Palmaz Genesis stent. The differences were statistically significant (p<0.01) between stents at each of the 3 levels of cross-sectional area reduction. CONCLUSION: There is a significant difference in the ability of different commercial "non-dedicated" stents to withstand a crushing force when deployed within endograft fenestrations, which has important implications for clinical practice.

Fenestrated aortic stent grafts.

Fenestrated stent grafts have been developed to offer an endovascular treatment option to those patients with abdominal aortic aneurysms whose infrarenal necks are anatomically unsuitable for endovascular repair with standard infrarenal devices. The ability to have customized fenestrations that will preserve flow to essential visceral arteries allows proximal seal and fixation to be achieved at and above the renal level. This article discusses patient selection, stent-graft design, and the importance of accurate planning. Deployment techniques along with complications and their avoidance are considered. The published midterm results are reviewed and appear to justify the continued use and evaluation of this technique as an alternative to open surgical repair in high-risk patients with infrarenal necks unsuitable for standard endovascular repair.