The results of subintimal angioplasty in a district general hospital.

OBJECTIVES AND DESIGN: we report a prospective study to determine if subintimal angioplasty can be performed in non-teaching centres and to establish its learning curve. MATERIALS AND METHODS: subintimal angioplasty was performed on 50 limbs in 46 patients (34 male) with a median age of 72 years (range 45-93 years). Indication was critical limb ischaemia (27 limbs) or intermittent claudication (23 limbs). Occlusions were located in the superficial femoral artery in 44 limbs, popliteal artery in 4 limbs and the peroneal artery in two limbs. At a median of 7.9 months patients had colour duplex imaging of the vessels that underwent angioplasty to assess vessel patency. RESULTS: primary technical success was achieved in 39 cases (78%). Primary technical success was greater in the second group of 25 consecutive limbs to undergo angioplasty at 92% (23 cases) compared with the first 25 consecutive limbs at 64% (16 cases). At 6 months the overall vessel patency rate on duplex imaging was 57%, improving to 64% in the group having a primarily successful procedure. The equivalent rate of symptomatic improvement was 59 and 66% respectively. Complications occurred in five procedures, most were minor, but a single fatality was directly attributable to the procedure. CONCLUSION: subintimal angioplasty can reasonably be performed outside major teaching institutions. There is a short learning curve associated with the procedure.

An audit of emergency abdominal aortic aneurysm repair to establish the necessity for an emergency vascular surgical rota.

Mortality for emergency abdominal aortic aneurysm (AAA) repair remains high but results of specialist vascular surgeons are superior to those of general surgeons. A retrospective audit was performed on all patients undergoing emergency AAA repair over 53 months at one hospital to determine the necessity for a vascular specialist on-call rota. Patients were stratified into two groups, those treated by specialist vascular surgeons and those treated by general surgeons. There were 37 patients in the vascular surgeon group and 36 in the general surgeon group. There was no significant difference between the two groups when age, sex distribution, APACHE II score on admission, pre-operative delay and type of rupture were considered. The average operating time was 114.7 min in the vascular surgeon group and 111.9 min in the general surgeon group. Total blood transfusion requirements, and postoperative duration of ventilation, inotrope therapy and intensive treatment unit stay were similar in the two groups. Intra-operative, 30-day and cumulative hospital mortalities were 10.8% versus 8.3%, 32.4% versus 38.9% and 40.5% versus 38.9% in the vascular surgeon and general surgeon groups, respectively. The mortality figures compare favourably with other published series. As the results of the two groups were similar, there is currently no need for vascular surgeons to be routinely available for acute AAA surgery at our hospital.

Predictive value of bruits and Doppler pressure measurements in detecting lower limb arterial stenosis.

The value of bruits and Doppler ankle pressure measurements as indicators of arterial stenosis was studied in 50 patients with symptoms of lower limb ischaemia. The iliac and femoropopliteal arteries were examined for bruits, ankle systolic pressures were measured before and after an exercise stress test and the results were compared to the findings of digital subtraction angiography (DSA). Patients with occlusive lesions in the iliac and femoropopliteal arteries were not analysed. This left a group of 37 symptomatic legs in which the popliteal pulse was palpable. In this sub-group, DSA demonstrated 25 limbs with arterial stenoses and 12 limbs without evidence of a stenosis. The presence of a bruit had a sensitivity of 80%, a specificity of 75%, a positive predictive value of 87%, a negative predictive value of 64% and an accuracy of 78%. A fall in Doppler ankle pressure of > or = 20 mmHg had a sensitivity of 92%, a specificity of 75%, a positive predictive value of 88%, a negative predictive value of 82% and an accuracy of 86%. When used selectively, clinical examination for bruits has good accuracy and may be of clinical value in the early identification of patients who are suitable for percutaneous transluminal angioplasty.

Factors influencing the healing of distal amputations performed for lower limb ischaemia.

A total of 235 toes were amputated during 125 operations on 100 consecutive patients with lower limb ischaemia. The overall amputation wound healing rate for the series was 58.4 per cent and limb salvage was achieved in 66 patients. Toe amputation was performed under local anaesthesia in 57 cases and 32 (56 per cent) of these healed primarily, not significantly different from the healing rate of 41 (60 per cent) of 68 under general anaesthesia. Reconstructive arterial surgery was performed in conjunction with toe amputation in 39 patients; the healing rate with reconstruction was 32 (82 per cent) of 39, significantly better than the 41 (48 per cent) of 86 patients not undergoing bypass surgery (P less than 0.001). There was no difference in healing rates when comparing diabetic and non-diabetic patients. Multiple regression analysis demonstrated that reconstructive arterial surgery was the only factor which had an independent and significant influence on toe amputation healing. The use of local anaesthesia for distal amputation has no deleterious effects on wound healing.

The natural history of small abdominal aortic aneurysms: an ultrasound study.

A retrospective study was undertaken to assess whether, using serial ultrasound examinations, the behaviour of small abdominal aortic aneurysms could be predicted. The average increase in size was found to be 0.3 cm/year. The pattern of increase in size was not affected by age, sex or the presence of hypertension. A proposed course of management of patients with small aneurysms is suggested, particularly if they have other significant medical problems.

A retrospective review of the outcome of patients over 70 years of age considered for vascular reconstruction in a district general hospital.

In the management of peripheral vascular disease advanced age has often been considered a relative contraindication to attempts at limb salvage procedures. However, failure to intervene may result in a high morbidity and mortality associated with loss of independence and quality of life. We present a review of patients over 70 years of age presenting with ischaemia of the lower limb who were considered for vascular reconstruction. A total of 214 patients had arteriograms between December 1979 and December 1985 in Derby. Following this, 99 (46%) had a vascular reconstruction as the primary procedure, 49 (23%) had an amputation as the primary procedure, and 66 (31%) did not have a major operation. Mortality was high (31% at 6 months), but there was no significant difference between those having amputation and those having vascular reconstruction. However, the outcome of vascular reconstruction in surviving patients was better in terms of independent mobility (63/70 vs. 16/38), long term care (9/70 vs. 22/38), use of hospital beds (27.2 vs. 69.9 days) and was more acceptable to the patient.

Limb salvage surgery in a district general hospital: factors affecting outcome.

In many patients with critical limb ischaemia, vascular reconstructive surgery is the only alternative to amputation to relieve severe rest pain or treat ischaemic ulcers and digital gangrene. Over a 4-year period, 402 patients with critical ischaemia of the lower limb were seen in the Derby Hospitals. One hundred and forty eight of these patients required primary amputation, 52 were treated with radiologically controlled angioplasty and in the remaining 208 patients, 218 surgical procedures for limb salvage were carried out. The overall operative mortality of patients undergoing limb salvage surgery was 9% with 72% of patients surviving 2 years or more. Postoperative mortality was greater in those patients over 70 years (16% vs 6% P less than 0.02). Patient survival at 2 years was reduced in patients over 70 years at the time of surgery (49% vs 83% P less than 0.001) and in those with 2 or more medical conditions (57% vs 71% P less than 0.001) present in the perioperative period. Overall limb salvage in surviving patients was 92% at 1 year and 91% at 2 years following surgery. Successful limb salvage at 2 years following femorodistal surgery alone was lower and related and to both infrapopliteal run off (2-3 vessels 87% vs 1 vessel 68% P less than 0.01) and the graft material used (vein 87%, Dardik 76%, Goretex 58%, P less than 0.01).

Experience with the 'skew flap' below-knee amputation.

A review of 353 lower limb amputations over the last 7 years has been performed to assess the results of the skew flap myoplastic below-knee amputation which was introduced in April 1983 because of reported advantages in terms of wound healing and earlier ambulation. Comparing the first 3 1/2 year period with the second, the total number of amputations decreased by 31 per cent. The number of above-knee amputations remained similar in the two periods (82,62), whilst the number of Gritti-Stokes amputations fell from 79 to 21 (0.001 greater than P greater than 0.01). The proportion of below-knee (BK) amputations increased from 50 (23.7 per cent) to 59 (41.5 per cent) (0.01 greater than P greater than 0.025). The groups were comparable in terms of previous vascular surgery and co-existing medical conditions. The time to full stump healing was significantly shorter in the skew flap group compared with the earlier Burgess type BK amputation (P = 0.001), and there was a trend to fewer stump failures in the skew flap group. We therefore feel that the skew flap amputation gives superior results to the Burgess BK amputation in terms of healing and a lower complication rate, allowing a higher proportion of BK amputations to be performed. A prospective randomized trial of the two techniques is in hand to determine the accuracy of this hypothesis.

Direct arterial pressure measurements during operation to assess adequacy of arterial reconstruction in lower limb ischaemia.

Over a 3-year period 164 patients undergoing arterial reconstruction for lower limb ischaemia had direct arterial pressure measurements during the operation. The arterial pressure was measured by direct puncture of the vessel with a No. 23 gauge needle connected, via a cannula, to a pressure transducer. The pressure was measured proximal and distal to anastomoses or endarterectomies, and note was made both of the absolute pressure and waveform. At 3 months 95 per cent were patent. In nine patients (5 per cent), there was a significant fall of pressure across the reconstructed artery and in eight of these procedures were carried out to correct the fault. The technique of direct arterial pressure measurement is quick and easy to perform, with equipment that is used routinely for monitoring by the anaesthetist. There has been no evidence of damage due to the arterial puncture itself. It provides a simple, objective assessment of adequacy of an arterial reconstruction and may lead to the early correction of otherwise unrecognized faults, and thus prevent early graft occlusion.

A definition of arteriomegaly and the size of arteries supplying the lower limbs.

A study has been made of the size of normal arteries supplying the lower limbs by measuring their circumferences at fixed points in cadavers and their diameters and lengths on aortographs. The arteriographs of a group of patients with dilated and elongated arteries have also been studied and a definition produced for the arteriographic condition known as arteriomegaly.