Myths and methodologies: Cardiopulmonary exercise testing for surgical risk stratification in patients with an abdominal aortic aneurysm; balancing risk over benefit.

The extent to which patients with an abdominal aortic aneurysm (AAA) should exercise remains unclear, given theoretical concerns over the perceived risk of blood pressure-induced rupture, which is often catastrophic. This is especially pertinent during cardiopulmonary exercise testing, when patients are required to perform incremental exercise to symptom-limited exhaustion for the determination of cardiorespiratory fitness. This multimodal metric is being used increasingly as a complementary diagnostic tool to inform risk stratification and subsequent management of patients undergoing AAA surgery. In this review, we bring together a multidisciplinary group of physiologists, exercise scientists, anaesthetists, radiologists and surgeons to challenge the enduring 'myth' that AAA patients should be fearful of and avoid rigorous exercise. On the contrary, by appraising fundamental vascular mechanobiological forces associated with exercise, in conjunction with 'methodological' recommendations for risk mitigation specific to this patient population, we highlight that the benefits conferred by cardiopulmonary exercise testing and exercise training across the continuum of intensity far outweigh the short-term risks posed by potential AAA rupture.

Uptake of risk-reducing surgery in BRCA gene carriers in Wales, UK.

Women who inherit a mutated copy of the BRCA gene have a higher lifetime risk of developing breast cancer. No large epidemiological studies exist looking at BRCA mutation carriers in UK populations. All patients with BRCA1/BRCA2 mutation identified between 1995 and 2015 were included. Individuals were identified from a prospectively gathered data base. Genetics case-notes were obtained and retrospective analysis performed. 581 female BRCA mutation carriers were identified with a median age of 34 (18-81) at the time of testing. Of the 301 women who underwent diagnostic testing (symptomatic) 246 had been diagnosed with breast cancer, 89 with ovarian cancer and 37 had both at time of testing. Median age at diagnostic test was 51 (25-81). 33% of women underwent risk-reducing mastectomies (RRM); median age at surgery 45. This compares with 37% of women in this diagnostic group who underwent Risk-reducing bilateral salpingo-oopherectomies (RRBSO) at a median age of 46. Two hundred and eighty women underwent predictive testing (family history, asymptomatic), median age 36 (18-81). 34% of women in this predictive group underwent RRM, median age 37. There was a 29% uptake of RRBSO (median age 44 years). Fifteen women (5%) developed breast cancer after being tested; none of these had undergone RRS. This unique study of all BRCA mutation carriers in Wales shows considerable variation in uptake of RRS. The decision to undergo RRS is complex and involves a number of factors, including a woman's age and life stage. As BRCA testing becomes more frequent and more gene mutation carriers are identified there will be significant implications for service allocation, screening demands, and provision of risk-reducing surgery for this high-risk patient group.

The Significance of Hypothermia in Abdominal Aortic Aneurysm Repair.

BACKGROUND: The aim of this study was to review the literature on the association between hypothermia and outcomes in open and endovascular abdominal aortic aneurysm (AAA) repair. The secondary aim was to determine whether there is a difference in body temperature in patients undergoing either transperitoneal (TP), retroperitoneal (RP), or endovascular surgical repair of the abdominal aorta (EVAR). METHODS: MEDLINE, Web of Science, and Trip searched for all studies on temperature in the context of aortic surgery or endovascular aortic interventions. To be included in the review, the papers had to be related to intraoperative or postoperative hypothermia and/or normothermia, with regards to either open or endovascular repair of the abdominal aorta. Thoracic or thoracoabdominal aortic repairs were not included for review. RESULTS: Eight studies involving 765 patients were eligible. Of these, 6 studies looked at open elective AAA repair involving 605 patients. Only 2 studies investigated emergency AAA repair and consisted of 160 patients where only 35 of those patients underwent emergency EVAR. Normothermic patients had a shorter length of stay in the intensive care unit (P = 0.0008), while hypothermia was independently associated with higher rates of organ dysfunction, in-hospital mortality, and prolonged hospital length of stay. In ruptured AAAs, the lowest average intraoperative temperature was recorded in open repair compared with EVAR (P = 0.02). There was no statistically significant difference in postoperative temperature between patients undergoing elective RP repair and those having TP surgery. CONCLUSIONS: The studies identified in this review have shown that hypothermia has numerous deleterious effects on outcomes in AAA repair - whether or not these adverse outcomes are those such as higher rates of organ dysfunction, mortality or prolonged hospital length of stay, can only be done at the single paper level and not at a literature review level, due to multiple confounding variables. Despite these limitations, the benefits of this review are numerous. This article highlights the importance of core body temperature and outcomes of AAA repair. Furthermore, it brings forth the need to standardize the method of core body temperature measurement and method of rewarming. Given the body of evidence so far, these standardized data collection points will be important for national vascular quality improvement initiatives. Only through rigorous analysis of standardized dataset can firm recommendation regarding peri- and postoperative temperature management be made.

Intervisceral artery origins in patients with abdominal aortic aneurysmal disease; evidence for systemic vascular remodelling.

NEW FINDINGS: What is the central question of this study? To what extent focal abdominal aortic aneurysmal (AAA) disease is associated with systemic remodelling of the vascular tree remains unknown. The present study examined whether anatomical differences exist between distances of the intervisceral artery origins and AAA location/size in patients with disease compared with healthy patients. What is the main finding and its importance? Intervisceral artery distances were shown to be consistently greater in AAA patients, highlighting the systemic nature of AAA disease that extends proximally to the abdominal aorta and its branches. The anatomical description of the natural variation in visceral artery origins has implications for the design of stent grafts and planning complex open aortic surgery. The initial histopathology of abdominal aortic aneurysmal (AAA) disease is atherosclerotic, later diverting towards a distinctive dilating rather than occlusive aortic phenotype. To what extent focal AAA disease is associated with systemic remodelling of the vascular tree remains unknown. The present study examined whether anatomical differences exist between the intervisceral artery origins and AAA location/size in patients with AAA disease (AAA+) relative to those without (AAA-). Preoperative contrast-enhanced computerized tomograms were reviewed in 90 consecutive AAA+ patients scheduled for open repair who underwent an infrarenal (n = 45), suprarenal (n = 26) or supracoeliac clamp (n = 19). These were compared with 39 age-matched AAA- control patients. Craniocaudal measurements were recorded from the distal origin of the coeliac artery to the superior mesenteric artery and from the origin of the superior mesenteric artery to both renal artery origins. Serial blood samples were obtained for estimation of the glomerular filtration rate before and after surgery. Intervisceral artery origins were shown to be consistently greater in AAA+ patients (P < 0.05 versus AAA-), although unrelated to AAA diameter (P > 0.05). Postoperative renal function became progressively more impaired the more proximal the clamp placement (estimated glomerular filtration rate for supracoeliac < suprarenal < infrarenal clamps, P < 0.05). These findings highlight the systemic nature of AAA disease that extends proximally to the abdominal aorta and its branches. The anatomical description of the natural variation in visceral artery origins has implications for the design of stent grafts and planning complex open aortic surgery.

A prospective longitudinal study of risk factors for abdominal aortic aneurysm.

The aim of this study was to identify risk factors for abdominal aortic aneurysm (AAA) from the largest Welsh screening cohort to date. Patients were recruited from 1993 (to 2015) as part of the South East Wales AAA screening programme through general practitioners. Demographic data and risk factors were collected by means of a self-report questionnaire. Statistical tests were performed to determine whether associations could be observed between AAA and potential risk factors. Odds ratios (OR) were also calculated for each of the risk factors identified. A total of 6879 patients were included in the study. Two hundred and seventy-five patients (4.0%) presented with AAA, of which 16% were female and 84% were male. Patients with AAA were older than the (no AAA) control group (p < 0.0001). The following risk factors were identified for AAA: family history of AAA (p < 0.0001); history of vascular surgery (p < 0.0001), cerebrovascular accident (p < 0.0001), coronary heart disease (p < 0.0001), diabetes (p < 0.0001), medication (p = 0.0018), claudication (p < 0.0001), smoking history (p = 0.0001) and chronic obstructive pulmonary disorder (p = 0.0007). AAA is associated with classical vascular risk factors, in addition to other less-well-documented risk factors including previous vascular surgery. These findings have practical implications with the potential to improve future clinical screening of patients in order to reduce AAA mortality.

Choledochoduodenostomy re-evaluated in the endoscopic and laparoscopic era.

BACKGROUND/AIMS: One of the options for draining an obstructed biliary tree is to form a choledochoduodenostomy (CDD). We evaluate our experience with this procedure with regard to complications (immediate and late), long term patency and patient survival. METHODOLOGY: An analysis was performed on a prospectively maintained database of all patients undergoing CDD under a single surgeon from 1992-2009. Data included pre-operative status, indications for surgery, postoperative morbidity and mortality, and complications. RESULTS: Sixty-eight CDDs were performed (40 male, 28 female). Thirty-seven (54%) were performed for benign disease (group A) and 31 (46%) for malignant disease (histologically confirmed, group B). Patients in group B were older (58 years vs. 69 years, p=0.009), and had higher preoperative bilirubin (58 vs. 156mg/dL, p=0.0003) and alkaline phosphatase (434 vs. 696 U/L, p=0.01). In hospital mortality was 7.5% in group A, and 9% in group B. Patients in group A had a shorter postoperative stay (p=0.008). Long-term mortality was significantly greater in group B (p<0.0001). Long term complications were lower in group A (14%) vs. group B (16%). In group B recurrent jaundice occurred in 3 patients (9.7%), of which 2 were successfully stented at ERCP, and one patient developed ascending cholangitis. CONCLUSIONS: CDD remains a relatively safe and effective surgical option for the treatment of obstructive jaundice in both benign and malignant disease. It remains a very useful tool where ERCP has failed, in patients with unresectable pancreatic malignancies, and in patients with recurrent choledocholithiasis.

Retroperitoneal Compared to Transperitoneal Approach for Open Abdominal Aortic Aneurysm Repair Is Associated with Reduced Systemic Inflammation and Postoperative Morbidity.

BACKGROUND: In the United Kingdom, the most common surgical approach for repair of open abdominal aortic aneurysms (AAAs) is transperitoneal (TP). However, retroperitoneal (RP) approach is favored in those with more complex vascular anatomy often requiring a cross-clamp on the aorta superior to the renal arteries. This study compared these approaches in patients matched on all major demographic, comorbid, anatomic, and physiological variables. METHODS: Fifty-seven patients (TP: n = 24; RP: n = 33) unsuitable for endovascular aneurysm repair underwent preoperative cardiopulmonary exercise testing prior to open AAA repair. The surgical approach undertaken was dictated by individual surgeon preference. Postoperative mortality, complications, and length of hospital stay (LoS) were recorded. Patients were further stratified according to infrarenal (IR) or suprarenal/supraceliac (SR/SC) surgical clamping. Systemic inflammation (C-reactive protein) and renal function (serum creatinine and estimated glomerular filtration rate) were recorded. RESULTS: Twenty-three (96%) of TP patients only required an IR clamp compared with 12 (36%) in the RP group. Postoperative systemic inflammation was lower in RP patients (p = 0.002 vs. TP) and fewer reported pulmonary/gastrointestinal complications whereas renal impairment was more marked in those receiving SR/SC clamps (p < 0.001 vs. IR clamp). RP patients were defined by lower LoS (p = 0.001), while mid-/long-term mortality was low/comparable with TP, resulting in considerable cost savings. CONCLUSION: Despite the demands of more complicated vascular anatomy, the clinical and economic benefits highlighted by these findings justify the more routine adoption of the RP approach for complex AAA repair.

Uncemented total hip arthroplasty can be used safely in the elderly population.

AIMS: "Get It Right First Time" (GIRFT) and NHS England's Best Practice Tariff (BPT) have published directives advising that patients over the ages of 65 (GIRFT) and 69 years (BPT) receiving total hip arthroplasty (THA) should receive cemented implants and have brought in financial penalties if this policy is not observed. Despite this, worldwide, uncemented component use has increased, a situation described as a 'paradox'. GIRFT and BPT do, however, acknowledge more data are required to support this edict with current policies based on the National Joint Registry survivorship and implant costs. METHODS: This study compares THA outcomes for over 1,000 uncemented Corail/Pinnacle constructs used in all age groups/patient frailty, under one surgeon, with identical pre- and postoperative pathways over a nine-year period with mean follow-up of five years and two months (range: nine months to nine years and nine months). Implant information, survivorship, and regular postoperative Oxford Hip Scores (OHS) were collected and two comparisons undertaken: a comparison of those aged over 65 years with those 65 and under and a second comparison of those aged 70 years and over with those aged under 70. RESULTS: Overall revision rate was 1.3% (13/1,004). A greater number of revisions were undertaken in those aged over 65 years, but numbers were small and did not reach significance. The majority of revisions were implant-independent. Single component analysis revealed a 99.9% and 99.6% survival for the uncemented cup and femoral component, respectively. Mean patient-reported outcome measures (PROMs) improvement for all ages outperformed the national PROMs and a significantly greater proportion of those aged over 65/69 years reached and maintained a meaningful improvement in their OHS earlier than their younger counterparts (p < 0.05/0.01 respectively). CONCLUSION: This study confirms that this uncemented THA system can be used safely and effectively in patient groups aged over 65 years and those over 69 years, with low complication and revision rates. Cite this article: Bone Jt Open 2021;2(5):293-300.

Ureteric complications and left retroperitoneal abdominal aortic surgery.

BACKGROUND: Open surgery for abdominal aortic aneurysms in the UK is usually performed via a midline transperitoneal incision. However, the left retroperitoneal (RP) approach may be beneficial for juxtarenal abdominal aortic aneurysms and certain physiological reasons. One potential disadvantage is that the left kidney usually requires mobilization anteromedially risking injury to the renal tract and possibly the ureter. METHODS: In this retrospective study, the time of onset, clinical presentation and treatment of left renal tract complications are scrutinized and discussed. Reasons for open aortic surgery as opposed to endovascular repair being undertaken were documented. Also, the aortic cross-clamp positions and type of reconstruction were examined. RESULTS: A total of 208 patients underwent RP aortic surgery for aneurysmal disease. The aortic cross-clamp positions were infrarenal in 115 (55%), suprarenal in 78 (38%) and supra-superior mesenteric artery or supracoeliac in 15 (7%). Two percent (4/208) sustained ureteric complications and all occurred in the upper third of the left ureter. The time of onset of symptoms ranged from 2 to 14 days post-operatively with a median of 3.5. Clinical signs were non-specific including pyrexia, tachycardia and flank pain. CONCLUSION: Ureteric complications following left RP aortic surgery is uncommon and usually occurs in the upper third of the renal tract. Trauma appears to be the most common cause, although ureteric ischaemia can occur but presents later particularly in those with comorbidities.

Aortic replacement in aorto-occlusive disease: an observational study.

BACKGROUND: For many patients with aorto-occlusive disease, where stent deployment is not possible, surgery remains the only treatment option available. The aim of this study was to assess the results of aortic reconstruction surgery performed in patients with critical ischaemia. METHODS: All patients with critical ischaemia undergoing surgery during 1991-2004 were identified from a prospectively maintained database. Mortality data was verified against death certificate data. Demographic and clinical data were obtained from the clinical notes and the radiology database. Disease was classified as: type I - limited to aorta and common iliac arteries; type II - external iliac disease and type III combined aortic, iliac and infra-inguinal disease. RESULTS: 86 patients underwent aortic replacement surgery all of whom had critical ischaemia consisting of: type I (n = 16); type II (n = 37) and type III (n = 33). The 30-day mortality rate was 10.4%, the one-year patient survival was 80%, and the 1-year graft survival was 80%. At 2 years the actual patient survival was 73% and no additional graft losses were identified. All patients surviving 30 days reported excellent symptomatic relief. Early, complications occurred in 6 (7%) patients: thrombosis within diseased superficial femoral arteries (n = 4); haemorrhage and subsequent death (n = 2). Ten (14%) late complications (> 12 months) occurred in the 69 surviving patients and included: anastomotic stenosis (n = 3); graft thrombosis (n = 4), graft infection (n = 3). Four patients developed claudication as a result of more distal disease in the presence of a patent graft, and 1 patient who continued smoking required an amputation for progressive distal disease. CONCLUSION: Aortic reconstruction for patients with extensive aorto-occlusive disease provides long-standing symptomatic relief for the majority of patients. After the first year, there is continued patient attrition due to co-existent cardiovascular disease but no further graft losses.

Has free radical release across the brain after carotid endarterectomy traditionally been underestimated? Significance of reperfusion hemodynamics.

BACKGROUND AND PURPOSE: Ischemia-reperfusion is an established paradigm for the induction of neuro-oxidative stress. The present report highlights the limitations associated with the measurement of free radical exchange across the human brain after carotid endarterectomy if reperfusion hemodynamics are not taken into account. Summary of Report- Only 2 human studies have reported local changes in the arterio-jugular bulb venous concentration difference (a-v(diff)) of free radicals during carotid endarterectomy. The authors reported either no change or only a very minor trans-cerebral release during the course of reperfusion, which was unexpected. However, consistent with other surgical models of ischemia-reperfusion, reperfusion would have been expected to increase plasma volume consistent with reflow-hemodilution. This would artifactually dilute the local concentration of free radicals, attenuate the a-v(diff) and thus underestimate the "true" magnitude of cerebral free radical release. CONCLUSIONS: After correction for reflow-hemodilution, the cerebral generation of free radicals after carotid endarterectomy is likely to be significantly more pronounced than previously documented in humans.

Mucinous adenocarcinoma presenting as an isolated sternal metastasis.

BACKGROUND: As a result of improvements in diagnostic accuracy, the primary source of the tumour is identified in more than 99% of cases presenting with a malignancy. Whilst the axial skeleton is a common site of metastases, the sternum is rarely affected, especially by isolated metastases. CASE PRESENTATION: We report a case of a 68 year old male who was referred to the surgical outpatient clinic with a six month history of sternal pain. The patient was known to have essential thrombocythaemia, which had recently transformed into acute myeloid leukaemia but a sternal biospy showed mucinous adenocarcinoma. He had not localising symptoms and full evaluation failed to localise the primary tumour. CONCLUSION: Solitary sternal metastases are rare and when found an underlying neoplasm is usually identified allowing targeted treatment. If however, there is no symptomatic tumour, the metastasis should simply be treated symptomatically.

Failure to account for practice effects leads to clinical misinterpretation of cognitive outcome following carotid endarterectomy.

Carotid endarterectomy (CEA) is a surgical procedure to remove stenotic atherosclerotic plaque from the origin of the carotid artery to reduce the risk of major stroke. Its impact on postoperative cognitive function (POCF) remains controversial; complicated, in part, by a traditional failure to account for practice effects incurred during consecutive psychometric testing. To address this for the first time, we performed psychometric testing (learning and memory, working memory, attention and information processing, and visuomotor coordination) in 15 male patients aged 68 ± 8 years with symptomatic carotid stenosis the day before and 24 h following elective CEA (two consecutive tests, 48 h apart). Multiple baselining was also performed in a separate cohort of 13 educationally, anthropometrically and age-matched controls (63 ± 9 years) not undergoing revascularization at identical time points with additional measures performed over a further 96 h (four consecutive tests, each 48 h apart). A single consecutive test in the control group resulted in progressive improvements in learning and memory, working memory, and attention and information (P < 0.05 vs. Test 1), with three tests required before cognitive performance stabilized. Following correction for practice effects in the patient group, CEA was associated with a deterioration rather than an improvement in learning and memory as originally observed (P < 0.05). These findings highlight the potential for the clinical misinterpretation of POCF unless practice effects are taken into account and provide practical recommendations for implementation within the clinical setting.

Vitamin C prophylaxis promotes oxidative lipid damage during surgical ischemia-reperfusion.

Reactive oxygen species (ROS) have been implicated in the cellular membrane damage and postoperative morbidity associated with obligatory ischemia-reperfusion (I-R) during vascular surgery. Thus, a clinical study was undertaken to evaluate the effects of ascorbate prophylaxis on ROS exchange kinetics in 22 patients scheduled for elective abdominal aortic aneurysm (AAA) or infra-inguinal bypass (IIB) repair. Patients were assigned double-blind to receive intravenous sodium ascorbate (2 g vitamin C, n=10) or placebo (0.9% saline, n=12) administered 2 h prior to surgery. Blood samples were obtained from the arterial and venous circulation proximal to the respective sites of surgical repair (local) and from an antecubital vein (peripheral) during cross-clamping (ischemia) and within 60 s of clamp release (reperfusion). Ascorbate supplementation increased the venoarterial concentration difference (v-adiff) of lipid hydroperoxides (LH), interleukin (IL)-6 and vascular endothelial growth factor (VEGF) protein during ischemia. This increased the peripheral concentration of LH, total creatine phosphokinase (CPK), and VEGF protein during reperfusion (P<0.05 vs placebo). Electron paramagnetic resonance (EPR) spectroscopy confirmed that free iron was available for oxidative catalysis in the local ischemic venous blood of supplemented patients. An increased concentration of the ascorbate radical (A.-) and alpha-phenyl-tert-butylnitrone (PBN) adducts assigned as lipid-derived alkoxyl (LO.) and alkyl (LC.) species were also detected in the peripheral blood of supplemented patients during reperfusion (P<0.05 vs ischemia). In conclusion, these findings suggest that ascorbate prophylaxis may have promoted iron-induced oxidative lipid damage via a Fenton-type reaction initiated during the ischemic phase of surgery. The subsequent release of LH into the systemic circulation may have catalyzed formation of second-generation radicals implicated in the regulation of vascular permeability and angiogenesis.

The thrombosed brachial-cephalic fistula used for renal dialysis--a cautionary note.

Arteriovenous fistulae (AVF) are commonly required for dialysis prior to renal transplantation, and are subsequently left insitu, even if thrombosed. The authors present one of two patients in whom progressive digital ischaemia occurred, and was initially overlooked, many years following formation of an AVF. The patient was surgically explored and clot protruding from the thrombosed vein into the brachial artery was noted. The arterial defect was closed with a vein patch and histological examination of the fistula confirmed clot. The patient recovered satisfactorily and remained well 6 months postoperatively. The authors would suggest that embolisation from a thrombosed AVF does occur, has a significant morbidity and can lead to digital loss. Furthermore, transplant patients are usually long suffering and will often put up with what they describe as 'aches and pains' as part of their illness. The authors suggest those patients suffering with evidence of ischaemia warrant excision of the fistula.

Haemostatic response to hypoxaemic/exercise stress: the dilemma of plasma volume correction.

OBJECTIVE: Patients with arterial occlusive disease are typically hypoxaemic, and exercise is prescribed for rehabilitation. Both stressors independently contract plasma volume (PV), which may influence clinical interpretation of a patient's thrombogenicity. The aim of the study was to emphasise the conceptual significance of PV correction. METHODS AND RESULTS: Venous plasma samples were obtained from 18 healthy men at rest in normoxia for the measurement of fibrinogen, prothrombin (PT), thrombin (TT) and activated partial thromboplastin (aPTT) times. Additional samples were obtained in hypoxia (12% oxygen) after 6 h of rest and immediately after a maximal exercise challenge. Haemostatic parameters were expressed before and after volume-shift correction. Passive hypoxia reduced PV by 3±5% (p<0.05 vs normoxia), with a further decrease observed during exercise (14±5%, p<0.05). The latter increased the absolute concentration of fibrinogen and shortened aPTT (p<0.05), but these changes were no longer apparent after PV correction (p>0.05). Likewise, the lack of change in absolute values for PT and TT (p>0.05) translated into an elongation after correction (p<0.05). CONCLUSIONS: These findings highlight the important, but previously ignored, interpretive implications of PV correction when haemostasis is assessed.

Variations in the anatomical distribution of peripheral vascular disease according to gender.

BACKGROUND: While large epidemiological studies have suggested that the male gender is more frequently afflicted with intermittent claudication, there is little data whether there are gender differences in the distribution of peripheral vascular disease (PVD). The aim of this study was to clarify this issue on the basis of angiographic findings in patients presenting with claudication. PATIENTS AND METHODS: The radiology department computerised database was used to identify all lower limb angiograms performed for investigation of PVD. Patients undergoing incomplete assessment and those with normal angiograms were excluded. Demographic details for each patient were collected together with details of uni- or bilaterality of disease, the number of lesions present and their anatomical distribution according to the major named vessels. Only lesions reported as radiologically significant were included in the analysis. RESULTS: Five hundred consecutive angiograms fitting the defined study criteria were assessed. There were 310 males and 190 females giving a male to female ratio of 1.6:1. The most common distribution for both genders was multiple bilateral lesions. There were no significant differences in the number of stenoses in terms of ratio of bilateral to unilateral (2.39 vs 2.77) or ratio of multiple to single lesions (1.5 vs 1.7) between the female and male groups. Disease was more common in males at all anatomical locations, the most significant differences being for lesions of the common femoral and profunda femoris arteries. CONCLUSIONS: PVD is more commonly diagnosed in males than females. The disease process is more commonly bilateral in both genders and PVD affects more numerous sites in the male claudicant than in the female claudicant. Nevertheless, there does not appear to be any difference in the anatomical distribution of disease between genders.

Surgical treatment of acute limb ischaemia in the presence of malignancy.

OBJECTIVES: The aim of this study was to examine the outcome of surgical treatment of acute limb ischaemia (ALI) developing in the presence of malignancy. METHODS: Patients undergoing emergency surgery were identified from theatre registers, notes were reviewed, and data collected in relation to indications for, and outcome following operation. All patients with a current or past medical history of histologically confirmed malignant disease were identified and their notes specifically reviewed to determine the staging of their tumours. The results of the malignancy cohort were compared to a group of patients undergoing surgery for ALI of other aetiologies. RESULTS: Fourteen patients with a malignancy were identified with ALI and in addition there were 102 without malignancy. The cohort with a malignancy contained a higher proportion of males (p=0.0305), and a greater number of smokers (p=0.037) than those with other aetiologies for ALI. The peri-operative management of the 2 groups was similar. Histological examination revealed tumour thrombus in only 1 case. The recurrence (29% versus 18%; p=0.328) and amputation rates (29% versus 17%; p=0.278) were similar, however, the 30-day (50% versus 30%; p=0.038) and 60-day mortality rates (100% versus 35%; p<0.001) were significantly higher in the malignancy group. CONCLUSIONS: The development of ALI in patients with malignant disease may be regarded as a terminal event despite comparable performance status at the time of surgery to those with other cause for ALI. The role of surgery in patients with known advanced malignancies appears to be of dubious benefit with little survival benefit.