All-Cause Mortality Amongst Patients Undergoing Above and Below Knee Amputation in a Regional Vascular Centre within 2014-2015.

BACKGROUND: Major lower limb amputation remains a common treatment for patients with peripheral vascular disease (PVD) in whom other measures have failed. It has been associated with high morbidity and mortality, including risks from venous thromboembolism (VTE). METHODS: A two-year retrospective cohort study was conducted involving 79 patients who underwent major lower limb amputation (below- or above-knee amputation) between January 2014 and December 2015 in a single tertiary referral centre. Amputation procedures were performed for reasons relating to complications of PVD and/or diabetes mellitus. Patients were followed-up to investigate all-cause mortality rates and VTE events using the Northern Ireland Electronic Care Record database (mean follow-up time 17 months). RESULTS: Of the 79 patients, there were 52 male and 27 female. Mean age at time of surgery was 72 years (range 34-99 years). Forty-six patients (58%) suffered from diabetes mellitus, 29 (35%) heart failure, 31 (39%) chronic kidney disease (CKD) and 10 (13%) chronic obstructive pulmonary disease (COPD). Twenty patients (25%) were on anticoagulant therapy, and 53 (67%) were on antiplatelet therapy.Thirty-five patients (44%) died during follow-up; mean age at death was 74 years. No statistically significant association was found between mortality rate and the level of amputation (p=0.3702), gender (p=0.3507), or comorbid diabetic mellitus (p=0.1127), heart failure (p=0.1028), CKD (p=0.0643) or COPD (p=0.4987).Two patients experienced radiologically-confirmed non-fatal pulmonary emboli and two patients developed radiologically-confirmed deep vein thrombosis. CONCLUSIONS: The results are in agreement with current literature that amputation is associated with significant mortality, with almost half of the study population dying during follow-up. Further work should explore measures by which mortality rates may be reduced.

Belfast Limb Arterial and Skeletal Trauma (BLAST): the evolution of punishment shooting in Northern Ireland.

INTRODUCTION: Northern Ireland has developed significant experience in specific punishment injuries due to its unique civil unrest. Simple gunshot wound (GSW) injuries have begun to evolve into more complex injuries. CASE PRESENTATION: We describe three cases of young male victims who suffered from GSW injuries-from a single GSW injury to multiple GSW injuries involving all four limbs; the phenomenon of Belfast Limb Arterial and Skeletal Trauma. We describe the management of these injuries, with a review of current literature. CONCLUSION: Due to the unique political situation of Northern Ireland, there has been significant development of surgical experience in GSW management. Historically, single knee-capping injuries were prevalent. However, these shootings have evolved into targeted injuries resulting in significant trauma as demonstrated by this case series.

Endovascular repair or open repair for ruptured abdominal aortic aneurysm: a Cochrane systematic review.

OBJECTIVES: Emergency endovascular aneurysm repair (eEVAR) may improve outcomes for patients with ruptured abdominal aortic aneurysm (RAAA). The study aim was to compare the outcomes for eEVAR with conventional open surgical repair for the treatment of RAAA. SETTING: A systematic review of relevant publications was performed. Randomised controlled trials (RCTs) comparing eEVAR with open surgical repair for RAAA were included. PARTICIPANTS: 3 RCTs were included, with a total of 761 patients with RAAA. INTERVENTIONS: Meta-analysis was performed with fixed-effects models with ORs and 95% CIs for dichotomous data and mean differences with 95% CIs for continuous data. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was short-term mortality. Secondary outcome measures included aneurysm-specific and general complication rates, quality of life and economic analysis. RESULTS: Overall risk of bias was low. There was no difference between the 2 interventions on 30-day (or in-hospital) mortality, OR 0.91 (95% CI 0.67 to 1.22; p=0.52). 30-day complications included myocardial infarction, stroke, composite cardiac complications, renal complications, severe bowel ischaemia, spinal cord ischaemia, reoperation, amputation and respiratory failure. Reporting was incomplete, and no robust conclusion was drawn. For complication outcomes that did include at least 2 studies in the meta-analysis, there was no clear evidence to support a difference between eEVAR and open repair. Longer term outcomes and cost per patient were evaluated in only a single study, thus precluding definite conclusions. CONCLUSIONS: Outcomes between eEVAR and open repair, specifically 30-day mortality, are similar. However, further high-quality trials are required, as the paucity of data currently limits the conclusions.

Predicted shortage of vascular surgeons in the United Kingdom: A matter for debate?

BACKGROUND: Vascular surgery became a new independent surgical specialty in the United Kingdom (UK) in 2013. In this matter for debate we discuss the question, is there a "shortage of vascular surgeons in the United Kingdom?" MATERIALS AND METHODS: We used data derived from the "Vascular Surgery United Kingdom Workforce Survey 2014", NHS Employers Electronic Staff Records (ESR), and the National Vascular Registry (NVR) surgeon-level public report to estimate current and predict future workforce requirements. RESULTS: We estimate there are approximately 458 Consultant Vascular Surgeons for the current UK population of 63 million, or 1 per 137,000 population. In several UK Regions there are a large number of relatively small teams (3 or less) of vascular surgeons working in separate NHS Trusts in close geographical proximity. In developed countries, both the number and complexity of vascular surgery procedures (open and endovascular) per capita population is increasing, and concerns have been raised that demand cannot be met without a significant expansion in numbers of vascular surgeons. Additional workforce demand arises from the impact of population growth and changes in surgical work-patterns with respect to gender, working-life-balance and 7-day services. CONCLUSIONS: We predict a future shortage of Consultant Vascular Surgeons in the UK and recommend an increase in training numbers and an expansion in the UK Consultant Vascular Surgeon workforce to accommodate population growth, facilitate changes in work-patterns and to create safe sustainable services.

Complex EVAR for abdominal aorto-iliac aneurysm (AAIA) is associated with high rate of endoleak and less aortic sac shrinkage compared to conventional EVAR for AAA.

INTRODUCTION: Endovascular repair (EVAR) for large abdominal aortic aneurysm (AAA) in anatomically suitable patients is associated with low early mortality and morbidity. However, EVAR is associated with a significant risk of late complication and a high cumulative re-intervention rate. Many large experienced centres have offered complex EVAR to challenging aortic anatomies such as abdominal aorto-iliac aneurysm (AAIA). We hypothesised that complex EVAR, for AAIA, would be associated with an increased risk of late graft-related complications. METHODS: The design was a Retrospective Clinical Cohort Study. From a prospective computerised database we identified consecutive patients undergoing EVAR in a single institution between 2008 and 2009. We retrieved analysis clinical data and digital Computed Tomographic Angiography (CTA) scans carried out pre-, early post-, and late post-EVAR. We compared patients undergoing complex EVAR for AAIA with those undergoing conventional standard EVAR for AAA. RESULTS: We identified 93 consecutive patients undergoing EVAR, 13 patients were excluded (3 eEVAR, 1 TEVAR, 9 data could not be retrieved) leaving 80 patients for analysis, 63 male and 17 female, average age 74.5 years (range 57-86), average follow-up 38 months (range 27-50), primary EVAR success was 100% and there was no mortality. Complex EVAR, EVAR plus internal iliac artery embolisation (+IIAE) and extension of the ipsilateral graft limb to the external iliac artery, for AAIA were carried out in 19/80 patients. After standard EVAR, late post-EVAR AAA sac diameter was significantly reduced in EVAR (63.24 ± 9.76 vs 54.26 ± 13.70, p < 0.001) but not after complex EVAR+IIAE (58.89 ± 16.39 vs 52.35 ± 12.75, p = 0.62). Endoleak these were significantly more common in the complex EVAR+IIAE, 5/19 (26.32%), as compared to the standard EVAR, 11/61 (18.03%), p < 0.01. Interestingly, inferior mesenteric artery (IMA) Patency was much commoner after complex EVAR+IIAE (15/19, 78.95%) compared EVAR (29/61, 47.54%), p < 0.01. CONCLUSION: EVAR can be carried out with low early mortality but has a significant risk of late complication, the commonest of which is endoleak. Complex EVAR for abdominal aorto-iliac aneurysm can be carried out with comparable results to conventional EVAR. However, high rates of persistent endoleak and inferior mesenteric artery patency, and lack of aneurysm sac shrinkage, would suggest they may be at increased risk of late complications and may benefit from enhanced and extended radiological surveillance.

The vascular surgery workforce: a survey of consultant vascular surgeons in the UK, 2014.

OBJECTIVE: The purpose of this study was to describe the demographics, training, and practice characteristics of consultant vascular surgeons across the UK to provide an assessment of current, and inform future prediction of workforce needs. METHODS: A questionnaire was developed using a modified Delphi process to generate questionnaire items. The questionnaire was emailed to all consultant vascular surgeons (n = 450) in the UK who were members of the Vascular Society of Great Britain & Ireland. RESULTS: 352 consultant vascular surgeons from 95 hospital trusts across the UK completed the survey (78% response rate). The mean age was 50.6 years old, the majority (62%) were mid-career, but 24% were above the age of 55. Currently, 92% are men and only 8% women. 93% work full-time, with 60% working >50 hours, and 21% working >60 hours per week. The average team was 5 to 6 (range 2-10) vascular surgeons, with 23% working in a large team of ≥8. 17% still work in small teams of ≤3. Over 90% of consultant vascular surgeons perform the major index vascular surgery procedures (aneurysm repair, carotid endarterectomy, infra-inguinal bypass, amputation). While 84% perform standard endovascular abdominal aortic aneurysm repair (EVAR), <50% perform more complex endovascular aortic therapy. The majority of vascular surgeons "like their job" (85%) and are "satisfied" (69%) with their job. 34% of consultant vascular surgeons indicated they were "extremely likely" to retire within the next 10 years. CONCLUSIONS: This study provides the first detailed analysis of the new specialty of vascular surgery as practiced in the UK. There is a need to plan for a significant expansion in the consultant vascular surgeon workforce in the UK over the next 10 years to maintain the status quo.

Endovascular repair of an inflammatory abdominal aortic aneurysm causing bilateral ureteric obstruction.

BACKGROUND: Conventional open repair of inflammatory abdominal aortic aneurysms (IAAA) remains challenging through the presence of extensive peri-aortic inflammation and fibrosis which makes dissection and vascular control difficult with a risk of inadvertent injury to adjacent visceral structures such as the ureters, duodenum, inferior vena cava, left renal vein and sigmoid colon. METHODS: We describe a case of a 69-year-old gentleman who presented with acute renal failure due to bilateral ureteric obstruction in association with an IAAA and discuss the various management options available. CONCLUSION: IAAAs and the associated peri-aortic inflammation and fibrosis can be successfully treated using endovascular abdominal aortic aneurysm repair with concurrent ureteric stenting.

Nurse-led rapid access vascular examination clinic triage reduces inappropriate referrals for peripheral arterial disease.

INTRODUCTION: Peripheral arterial disease causing intermittent claudication (IC) causes decreased quality of life and significant morbidity. We hypothesized that triage of patients referred with suspected IC at a nurse-led rapid access vascular examination (RAVE) clinic would identify those patients requiring vascular surgery assessment. METHODS: A prospective cohort study was performed. Patients referred with suspected IC were assessed using the Edinburgh claudication questionnaire (ECQ) and arterial Doppler assessment with segmental waveform analysis and calculation of ankle brachial pressure index (ABPI). Data were collected regarding cardiovascular risk and its modification. RESULTS: Of 451 consecutive patients, mean age was 65 years (range 30-89). Cardiovascular risk factors included: 173/451 (38%) current smokers (162/451 (36%) were ex-smokers); diabetes, 22%; hypertension, 46%; ischaemic heart disease (angina), 29%; dyslipidaemia, 27%. Therapeutic risk modifications included: antiplatelet therapy, 64.4%; lipid-lowering therapy, 57.8%. abnormal ABPI readings were present in 264/451 (59%), with ratio <0.9 in 209/451 (46.3%), >1.3 in 48/451 (10.6%), and incompressible vessels 7/451 (1.5%). Normal ABPI (ratio >0.9 and <1.3, triphasic Doppler waveforms) were found in 187/451 (41%), these patient were considered inappropriate referrals. Considering those patient with PAD diagnosed on abnormal ABPI (<0.9 or >1.3), Doppler waveform analysis was more sensitive and specific than ECQ. CONCLUSIONS: Diagnosis of IC with clinical history alone is inaccurate in 41 percent of cases, leading to inappropriate referral to vascular surgery. Doppler waveform analysis had excellent sensitivity and specificity for prediction of ABPI <0.9. ABPI measurement in primary care could result in a more efficient use of clinical resources.

Triglyceride to HDL ratio is a reliable predictor of adverse outcomes in risk stratification for candidates undergoing abdominal aortic surgery.

INTRODUCTION: The aim of this study was to establish if an elevated triglyceride to high-density lipoprotein (HDL) ratio (THR) is not only a risk factor for cardiovascular and overall morbidity as the updated evidence shows, but could also be employed as a significant predictor for surgical adverse outcomes and hence be a valid tool for risk stratification of candidates undergoing abdominal aortic surgery. METHODS: This is a single-centre retrospective analysis of 2224 patients who underwent open abdominal aortic surgery between January 1996 and 2009. This cohort was divided into quartiles of THR. A list of covariates has been entered with THR into a multiple logistic model with forwards stepwise selection. The obtained result is an adjusted model, conceived to establish the association between THR and perioperative adverse events. Discrimination of the model so obtained and comparison with vascular-specific risk stratification scoring systems were evaluated using the area under the receiver operating characteristic (AUROC). RESULTS: THR had the highest predictive value for the outcomes of interest. The adjusted odds ratios (ORs) per every 0.1 augmentation of THR were 1.41 (1.08-1.88) for cardiac, 1.38 (1.09-1.84) for respiratory, 1.27 (1.06-1.54) for renal adverse events and 1.02 (0.84-1.23) for mortality. Regarding mortality, either of the scoring systems Vascular Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and customised probability index (CPI) and the THR ranked as moderate discriminators, with THR performing the worst (AUROC 0.71) compared with Vascular POSSUM (AUROC 0.76) and CPI (AUROC 0.78). THR performed as a very strong predictor of morbidity (AUROC 0.86), ranking above Vascular POSSUM (AUROC 0.72). CONCLUSIONS: THR is a significant predictor of perioperative morbidity and mortality. THR offers a broad outlook on the metabolic state of patients undergoing major abdominal aortic surgery and hence their propensity to adverse events, allowing us to risk-stratify the prognostic outcome of surgical intervention and possibly intervene preoperatively to optimise results.

Successful delayed secondary open conversion after endovascular repair using partial explantation technique: a single-center experience.

BACKGROUND: Endovascular aneurysm repair (EVAR) reduces the morbidity and mortality associated with abdominal aortic aneurysm repair, but in some patients endoleak or aneurysm expansion may necessitate secondary open conversion (SOC). We reviewed the outcomes after delayed SOC following EVAR in consecutive patients at a single center. METHODS: We retrospectively reviewed all patients undergoing EVAR to identify a cohort undergoing delayed SOC in a single center between 1998 and 2008. We analyzed delayed SOC patients for operative indications, technique, and early outcomes. We made specific comment on the surgical techniques used, with respect to partial or total endograft explantation. RESULTS: Delayed SOC was carried out in 10/285 (3.5%) consecutive patients implanted with the Zenith endograft; during this period, two further patients had SOC after initial EVAR in another center. Graft types were Zenith (n = 10), Talent (n = 1), and AneuRx (n = 1). Indications for open conversion were infected graft (n = 3), sac expansion (n = 3), type 1 endoleak (n = 2), type 2 endoleak (n = 2), juxtarenal aneurysm (n = 1), and rupture (n = 1). Explantation techniques were partial explantation with in situ replacement (n = 7), full explantation with axillobifemoral bypass (n = 3), in situ replacement (n = 1), and suturing (n = 1)Complete stent explantation was required in 4 patients with axillo-bifemoral bypass in three of them. 7 patients had partial stent explantation and one patient stent was left insitu. Postoperative morbidities included myocardial infarction (n = 1), renal dialysis (n = 1), and chest infection (n = 3). No 30-day mortality was noted, and all patients were discharged from hospital and remain well with median follow-up of 5 months (interquartile range 1.7-26.7). CONCLUSION: SOC after EVAR is feasible in selected patients with low morbidity and mortality. Partial explantation with in situ replacement, in the absence of sepsis, may be the preferred revascularization option but may require long-term follow-up.

The role of transthoracic echocardiography in embolic acute limb ischaemia.

INTRODUCTION: Embolic acute limb ischaemia (ALI) is commonly treated by re-vascularization and long-term anticoagulant therapy. Transthoracic echocardiography (TTE) is commonly used to screen for cardiac embolic source, but may not affect management. REPORT: We reviewed 115 consecutive patients with embolic ALI, 61% underwent TTE, with cardiac thrombus identified in only 3%. Incidental severe abnormalities requiring further cardiological investigation were detected in 19% of patients. Inpatient TTE did not affect mortality, morbidity, amputation rate, or anticoagulation. DISCUSSION: Transthoracic echocardiography seldom identifies a cardiac embolic source, but identifies many patients with severe incidental cardiac abnormalities, suggesting cardiology screening of these patients remains important.

Surgical debulking in a case of chronic lymphoedema.

Lymphoedema can present with an array of distressing symptoms, which can pose significant management dilemmas. First-line treatment involves established therapies including elevation, manual drainage and compression hosiery. However, failure of these medical strategies can occasionally necessitate surgical intervention to alleviate symptoms. This case highlights the role of surgical debulking in the management of an intractable case of lower limb lymphoedema with symptoms so severe that the patient requested amputation of her left lower extremity. This report also describes other surgical modalities in the management of this debilitating condition.

Positive fluid balance is associated with complications after elective open infrarenal abdominal aortic aneurysm repair.

BACKGROUND: Open abdominal aortic aneurysm (AAA) repair is associated with cardiac and respiratory complications and an overall mortality rate of 2 to 8%. We hypothesised that excessive fluid administration during the perioperative period contributes to complications and poor outcome after AAA repair. METHODS: This was a retrospective cohort study. Medical records were analysed for fluid balance and complications in 100 consecutive patients treated by open AAA repair at a single centre between 2002-2005. Mortality and all major adverse events (MAE) such as myocardial infarction (MI), cardiac arrhythmia (Arr), pulmonary oedema (PO), pulmonary infection (PI), and acute renal failure (ARF) were included in the analysis. Level of care and hospital stay, were also recorded. RESULTS: There were no in-hospital deaths. MAE occurred in 40/100 (40%): MI (6%); Arr (14%); PO (14%); PI (25%); ARF (8%). Complications were not predicted by preoperative cardiovascular risk factors, operative and clamp time, or blood loss. Patients with complications had significantly greater cumulative positive fluid balance on postoperative day 0 (p<0.01), day 1 (p<0.05), day 2 (p<0.03) and day 3 (p<0.04). This relationship also existed for individual complications such as MI, and pulmonary oedema. These patients had significantly longer ICU/HDU (p<0.002) and hospital stay (p<0.0001). CONCLUSIONS: Serious complications are common after elective open AAA repair, and we have shown that positive fluid balance is predictive of major adverse events increased HDU/ICU and overall hospital stay.

Endovascular ruptured abdominal aortic aneurysm repair (EVRAR): a systematic review.

BACKGROUND: To review evidence supporting the use of endovascular ruptured aneurysm repair (EVRAR) for treatment of ruptured abdominal aortic aneurysm (RAAA). METHODS: A systematic review of the medical literature was performed for relevant studies. We searched a number of electronic databases and hand-searched relevant journals until November 2006 to identify studies for inclusion. We considered studies in which patients with a confirmed ruptured abdominal aortic aneurysm were treated with EVRAR, which reported endpoints of mortality and major complications. RESULTS: There was 1 randomised controlled trial (RCT), 33 non-randomised case series (24 retrospective and 9 prospective) reports were identified comparing EVRAR (n=891) with conventional open surgical repair for the treatment of RAAA. Whilst no benefit in the primary outcome of mortality was noted in the only RCT, evidence from non-randomised studies suggest that EVRAR is feasible in selected patients, where it may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, early complications, and mortality. CONCLUSIONS: For the treatment of symptomatic or ruptured abdominal aortic aneurysm, emergency endovascular repair (EVRAR) is feasible in selected patients, with early outcomes comparable to best conventional open surgical repair for the treatment of RAAA.

Endovascular treatment for ruptured abdominal aortic aneurysm.

BACKGROUND: An abdominal aortic aneurysm (AAA) (the pathological enlargement of the aorta) can develop in both men and women as they grow older. It is most commonly seen in men over the age of 65 years. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, a fatal event unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains high (approximately 50%) after conventional open surgical repair. A newer minimally invasive technique, endovascular repair, has been shown to reduce early morbidity and mortality, as compared to conventional open surgery, for planned AAA repair. Emergency endovascular repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible in selected patients. However, it is not yet known if eEVAR will lead to significant improvements in outcomes for these patients or indeed if it can replace conventional open repair as the preferred treatment for this lethal condition. OBJECTIVES: To compare the advantages and disadvantages of eEVAR in comparison with conventional open surgical repair for the treatment of RAAA. SEARCH STRATEGY: The Cochrane Peripheral Vascular Diseases Group searched their trials register (last searched October 2006) and the Cochrane Central Register of Controlled Trials (CENTRAL) database (last searched Issue 4, 2006). We searched a number of electronic databases and handsearched relevant journals until March 2006 to identify studies for inclusion. SELECTION CRITERIA: Randomised controlled trials in which patients with a confirmed ruptured abdominal aortic aneurysm were randomly allocated to eEVAR, or conventional open surgical repair. DATA COLLECTION AND ANALYSIS: Studies identified for potential inclusion were independently assessed for eligibility by at least two reviewers, with excluded studies further checked by the agreed arbitrators. As no randomised controlled trials were identified at present no tests of heterogeneity or sensitivity analysis were performed. MAIN RESULTS: There were no randomised controlled trials identified at present comparing eEVAR with conventional open surgical repair for the treatment of RAAA. AUTHORS' CONCLUSIONS: There is no high quality evidence to support the use of eEVAR in the treatment of RAAA. However, evidence from prospective controlled studies without randomisation, prospective studies, and retrospective case series suggest that eEVAR is feasible in selected patients, with outcomes comparable to best conventional open surgical repair for the treatment of RAAA . Furthermore, endovascular repair in selected patients may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, and mortality.

Anti-endotoxin hyperimmune globulin attenuates portal cytokinaemia, phagocytic cell priming, and acute lung injury after lower limb ischaemia-reperfusion injury.

OBJECTIVES: Acute limb ischaemia is a common and often lethal clinical event. Reperfusion of an ischaemic limb has been shown to induce a remote gut injury associated with transmigration of endotoxin into the portal and systemic circulation, which in turn has been implicated in the conversion of the sterile inflammatory response to a sepsis syndrome, after lower torso ischaemia-reperfusion injury. This study tests the hypothesis that an anti-endotoxin hyperimmune globulin attenuates ischaemia-reperfusion (I/R) associated sepsis syndrome. DESIGN: Prospective, randomised placebo controlled trial, animal experiment. MATERIALS AND METHODS: Experimental porcine model, bilateral hind limb I/R injury, randomised to receive anti-endotoxin hyperimmune globulin or placebo. RESULTS: Bilateral hind limb I/R injury significantly increased intestinal mucosal acidosis, portal endotoxaemia, plasma cytokine (TNF-alpha, IL-6, IL-8) concentrations, circulating phagocytic cell priming and pulmonary leukosequestration, oedema, and capillary-alveolar protein leak. Conversely, pigs treated with anti-endotoxin hyperimmune globulin (IgG) 20mg/kg at onset of reperfusion had significantly reduced portal endotoxaemia, early circulating phagocytic cell priming, plasma cytokinaemia and attenuation of acute lung injury. CONCLUSIONS: Endotoxin translocation across a hyperpermeable gut barrier, phagocytic cell priming and cytokinaemia are key events of limb I/R injury induced systemic inflammation and acute lung injury. This study shows that an anti-endotoxin hyperimmune globulin attenuates portal endotoxaemia, which may reduce early phagocytic cell activation, cytokinaemia and ultimately acute lung injury.

The Belfast approach to managing complex lower limb vascular injuries.

INTRODUCTION: Complex lower limb vascular injuries (CLVIs) in high-energy penetrating or blunt trauma are associated with an unacceptably high incidence of complications including amputation. Traumatic ischaemia and ischaemia-reperfusion injury (IRI) of skeletal muscle often lead to limb loss, the systemic inflammatory response syndrome (SIRS) which affects remote organs and even the potentially fatal multiple organ dysfunction syndrome (MODS). Surgical care of CLVIs everywhere, including Northern Ireland until 1978, was governed by an anxiety to restore arterial flow quickly often using expedient and flawed repair techniques while a damaged major vein was frequently ligated. MATERIALS AND METHODS: A new policy centred on early intraluminal shunting of both artery and vein, restoring arterial inflow and venous outflow, respectively, was introduced at the Regional Vascular Surgery Unit of The Royal Victoria Hospital, Belfast in 1979. It imposed a disciplined one-stage comprehensive approach to treatment involving a sequence of operative manoeuvres in which all damaged anatomical elements receive meticulous and optimal attention unshackled by time constraints. RESULTS: Comparisons drawn between the pre-shunt period of unplanned treatment (1969-1978) and the post-shunt period centred on the use of shunts (1979-2000) showed that early shunting of both artery and vein in both penetrating (P) and blunt (B) injuries significantly reduced the necessity for fasciotomy (P: p=0.016, B: p=0.02) and caused a significant fall in the incidence of contracture (P: p=0.018, B: p=0.02) and of amputation (P: p=0.009, P: p=0.012). CONCLUSIONS: The policy of early shunting of artery and vein in CLVIs has proved to be of great benefit in terms of significantly improved outcomes, better operative discipline and harmonious collaboration among the specialists involved.

Periods of low atmospheric pressure are associated with high abdominal aortic aneurysm rupture rates in Northern Ireland.

Seasonal and circadian variation in the incidence of ruptured abdominal aortic aneurysm (RAAA) has been reported. We explored the role of atmospheric pressure changes on rupture incidence and its relationship to cardiovascular risk factors. During a three year-period, 1st April 1998 and 31st March 2001, data was prospectively acquired on 144 Ruptured Abdominal Aortic Aneurysm (RAAA) presenting to the Regional Vascular Surgery Unit at the Royal Victoria Hospital, Belfast, Northern Ireland. For each patient the chronology of acute onset of symptoms and presentation to the regional vascular unit was recorded, along with details of standard cardiovascular risk factors. During the same period meteorological data including atmospheric pressure and air temperature were recorded daily at the regional meteorological research unit, Armagh. We then analyzed the monthly mean values for daily rupture incidence in relation to the monthly values for atmospheric pressure, pressure change and temperature. Furthermore atmospheric pressure on the day of rupture, and day preceding rupture, were also analyzed in relation to days without rupture presentation and between individual ruptures for various cardiovascular risk factors. Data demonstrated a significant monthly variation in aneurysm rupture frequency, (p<0.03, ANOVA). There was also a significant monthly variation in mean barometric atmospheric pressure, (p<0.0001, ANOVA), months with high rupture frequency also exhibiting low average pressures in the months of April (0.24 +/- 0.04 ruptures per day and 1007.78 +/- 1.23 mB) and September (0.16 +/- 0.04 ruptures per day and 1007.12 +/- 1.14 mB), respectively. The average barometric pressures were found to be significantly lower on those days when ruptures occurred (n=1127) compared to days when ruptures did not occur (n=969 days), (1009.98 +/- 1.11 versus 1012.09 +/- 0.41, p<0.05). Full data on risk factors was available on 103 of the 144 rupture patients and was further analyzed. Interestingly, RAAA with a known history of hypertension, (n=43), presented on days with significantly lower atmospheric pressure than those without, (n=60), (1008.61 +/- 2.16 versus 1012.14 +/- 1.70, p<0.05). Further analysis of ruptures grouped into those occurring on days above or below mean annual atmospheric pressure 1013.25 (approximately 1 atmosphere), by Chi-square test, revealed three cardiovascular risk factors significantly associated with low-pressure rupture, (p<0.05). Data represents mean +/- SEM, statistical comparisons with Student t-test and ANOVA. These data demonstrate a significant association between periods of low barometric pressure and high incidence of ruptured aneurysm, especially in those patients with known hypertension. The association between rupture incidence and barometric pressure warrants further study as it may influence the timing of elective AAA repair.