Infrapoliteal percutaneous transluminal angioplasty: A safe and successful procedure

Aim:To review outcome of 40 consecutive infrapopliteal percutaneous transluminal angioplasty (PTA) procedures performed over a 65 month period.Chief outcome measures:The indication for PTA was intermittent claudication in 20 (50%) cases and rest pain, ulceration or gangrene in the remainder.Results:There was one technical failure; the remaining 39 limbs were all clinically improved by 24 h and this improvement was maintained at 3 months in 36 (90%). There were no deaths nor limb loss related to PTA and 2 embolic complications were successfully treated percutaneously. The primary and secondary symptomatic patencies at 24 months were 59 and 79% respectively. The actuarial limb salvage rate at 1 year for the 20 limbs presenting with critical ischaemia was 77%, and 10 of the 14 procedures performed for ulceration or gangrene resulted in healing with only minor surgical intervention.Conclusions:With modern endovascular techniques, infrapopliteal PTA is a safe, worthwhile and durable procedure

At what peak velocity ratio value should duplex-detected infrainguinal vein graft stenoses be revised?

Objectives:To determine the peak velocity ratio (PVR) threshold at which to intervene and correct duplex detected vein graft stenoses.Design:Prospective study.Materials:Infrainguinal vein grafts in patients attending the vascular studies for routine postoperative surveillance.Methods:Colour duplex detected stenotic vein graft lesions with a peak velocity ratio (PVR) between 2.0 and 2.9 were identified and monitored by serial duplex scans performed monthly for 3 months and then at 3-monthly intervals thereafter. At the end of the study period, the outcome of these lesions were analysed.Results:Thirty-eight lesions were identified from 32 grafts. Of these lesions, sixteen (42%) resolved, 11 (29%) remained stable and 11 (29%) progressed to a PVR of ≥3.0 and underwent angioplasty. There were no occlusions in any of the grafts during the period of study.Conclusion:Colour duplex detected vein graft stenoses with a PVR of less than 3.0 can be treated expectantly if grafts with stenoses with a PVR 2.0–2.9 are scanned every month for at least 3 months after detection

Bilateral infrainguinal vein grafts and the incidence of vein graft stenosis

Objectives:To elucidate the incidence of significant vein graft stenosis in patients who have undergone bilateral infrainguinal vein grafts.Materials:Between 1987 and 1996, 22 patients were identified from our vascular studies database as having undergone bilateral infrainguinal vein bypass grafting.Methods:Data was obtained from the vascular studies database and by case note review. All patients had been part of a vein graft surveillance programme.Results:Of the 22 patients with bilateral vein grafts, eight were excluded from further analysis because one or more of their grafts failed within 30 postoperative days. In the remaining 14 patients (28 vein grafts) there were 15 primary vein graft stenoses. Six patients (43%) had bilateral vein graft stenoses, which is significantly higher (p = 0.0008) than the predicted value of 9%, for developing bilateral vein graft stenoses. For those patients who developed a vein graft stenosis in their first grafted limb (9/14), 67% (6/14) subsequently developed a vein graft stenosis in their second grafted limb.Conclusion:Patients who develop vein graft stenosis in one limb are at a greater risk of developing a contralateral vein graft stenosis if that limb is grafted. This may well be due to individual vein morphology or unidentified systemic factors that play a role in the aetiology of vein graft stenosis

The increasing activity of a vascular ultrasound service

Objectives:To examine the change in activity of a vascular ultrasound service over 7 years.Design:Retrospective review.Setting:Vascular studies unit, University hospital.Method:Audit of the number of vascular ultrasound tests carried out over the last 7 years using a prospective computerised database.Results:Data shows that the overall workload has tripled over the 7-year period. In addition the complexity of investigations has increased during this time. The number of carotid scans has increased four-fold while the number of graft surveillance scans and vein scans has increased seven-fold. Assessment of lower limb arteries has developed from simple pressure measurements to detailed ultrasound scans and, as a consequence, the number of diagnostic angiograms has fallen by 75%. The factors that have influenced these changes are discussed.Conclusion:There has been an important increase in the role of colour Doppler ultrasound as it becomes the “first line” vascular diagnostic test. However this trend can only continue if vascular ultrasound services are appropriately resourced. It is therefore essential to maintain an efficient audit system

A clinical and haemodynamic investigation into the role of calf perforating vein surgery in patients with venous ulceration and deep venous incompetence

Objective:To determine the clinical efficacy and local haemodynamic effects of perforating vein surgery in ulcerated limbs with combined deep and perforating vein incompetence.Design:Prospective, interventional study.Materials and methods:Seven ulcerated limbs with combined primary deep and perforating vein incompetence were studied. Clinical efficacy was determined by ultimate ulcer healing and reduction in ulcer area, local haemodynamics were assessed at three sites with photoplethysmographic 90% venous refilling times (PPG RT90); both assessments were performed pre- and 1-month postoperatively.Results:None of the ulcers healed following perforating vein surgery, the median (range) ulcer areas pre- and postoperatively were 31 (7–685) cm2 and 35.5 (7–796) cm2 (Wilcoxon p = 0.07). Preoperative PPG RT90 demonstrated a global abnormality of venous function at all sites examined that persisted after perforating vein surgery.Conclusion:In the presence of deep venous incompetence perforating vein surgery had no influence on venous function or ulcer healing. We conclude that perforating vein surgery is not indicated for the treatment of venous ulceration in limbs with primary deep venous incompetence

Results of surgery and angioplasty for the treatment of chronic severe lower limb ischaemia

Objective:The aim of this study was to assess and compare the efficacy of PTA and surgery in the treatment of severe lower limb ischaemia.Design:Prospective 12-month study of 180 consecutive patients with severe chronic lower limb ischaemia.Methods:PTA was used as first line therapy whenever possible and appropriate. Surgical revascularisation, primary amputation and conservative therapy were used in the remaining patients. Patient survival and limb salvage were derived using life table analysis.Results:Revascularisation was attempted in 135 (75%) patients, with PTA in 82 (46%), surgery in 49 (27%) and a combination of both in four (2%). Overall 12-month survival and limb salvage was 75% and 71%, respectively. Surgery and PTA had significantly higher survival rates (91% and 78%) than primary amputation or conservative therapy (57% and 52%) (p<0.0001 log rank test). Revascularisation with either surgery or PTA achieved the same limb salvage rate of 76%.Conclusion:A large proportion of patients with severe chronic lower limb ischaemia can be managed by PTA. This management strategy produces a clinically effective outcome at 1-year

The physiological effects of elevated intra-abdominal pressure following aneurysm repair

AbstractObjectives: elevated intra-abdominal pressure (IAP) may cause widespread organ dysfunction (abdominal compartment syndrome) through effects on the respiratory, cardiac, renal and gastro-intestinal systems. The aim of this study was to document IAP following aneurysm surgery, and to determine the effect of IAH on outcome. Design: prospective observational study. Setting: University Hospital. Subjects: the patient cohort comprised 75 patients undergoing infra-renal aneurysm repair (53 non-ruptured [40 conventional - 1 death, 13 endovascular] and 22 conventionally repaired ruptured AAA - 8 deaths). IAP was quantified by bladder manometry at the termination of the procedure and at 24 h intervals in patients who remained intubated. Physiological indices of organ function were recorded. Statistical analysis utilized the unpaired t-test, Fischer's exact test and Pearson's correlation. Results: IAP was significantly higher at abdominal closure following ruptured aneurysm repair (15.4 mmHg [SE 1.6]) than conventional (10.5 [0.89]) or endovascular elective repair (6.4 [1.0]) of non-ruptured AAA. The sensitivity and specificity of IAP to predict subsequent mortality was analysed using a receiver characteristic operating curve. This analysis demonstrated that a cut off of 15 mmHg was the most useful for indicating patients at risk (sensitivity 0.66, specificity 0.79). Physiological indices of organ dysfunction (pH[p = 0.027], base excess [p = 0.005], peak inspiratory pressure [p = 0.0015], CVP and urine output [p = 0.0029]) were significantly impaired in patients with IAP ≥ 15 mmHg, in comparison to patients with lower pressures. IAP correlated significantly with indices of cardiac (CVP p = 0.038), respiratory (PaO2/FiO2, p = 0.026), and renal function (urine output p = 0.046). Conclusions: these data suggest that the management of IAH may have a role following repair of ruptured AAA. High intra-abdominal pressures rarely complicate elective or endovascular aneurysm repair.Eur J Vasc Endovasc Surg 26, 293-298 (2003

A Policy of Quality Control Assessment Helps to Reduce the Risk of Intraoperative Stroke During Carotid Endarterectomy

AbstractObjectivesa pilot study in our unit suggested that a combination of transcranial Doppler (TCD) plus completion angioscopy reduced incidence of intra-operative stroke (i.e. patients recovering from anaesthesia with a new deficit) during carotid endarterectomy (CEA). The aim of the current study was to see whether routine implementation of this policy was both feasible and associated with a continued reduction in the rate of intraoperative stroke (IOS).Materials and methodsprospective study in 252 consecutive patients undergoing carotid endarterectomy between March 1995 and December 1996.Resultscontinuous TCD monitoring was possible in 229 patients (91%), while 238 patients (94%) underwent angioscopic examination. Overall, angioscopy identified an intimal flap requiring correction in six patients (2.5%), whilst intraluminal thrombus was removed in a further six patients (2.5%). No patient in this series recovered from anaesthesia with an IOS, but the rate of postoperative stroke was 2.8%.Conclusionsour policy of TCD plus angioscopy has continued to contribute towards a sustained reduction in the risk of IOS following CEA, but requires access to reliable equipment and technical support. However, a policy of intra-operative quality control assessment may not necessarily alter the rate of postoperative stroke

Transcranial Doppler Directed Dextran Therapy in the Prevention of Carotid Thrombosis: Three Hour Monitoring is as Effective as Six Hours

AbstractBackgroundsix hours» monitoring by transcranial Doppler (TCD) has been successful in directing Dextran therapy in patients at high risk of thrombotic stroke after carotid endarterectomy (CEA).Objectivesis 3 h of routine monitoring as effective as 6 h in the prevention of early postoperative thrombotic stroke?Designprospective, consecutive study in all patients with an accessible cranial window.Methodsone hundred and sixty-six patients undergoing CEA underwent 3 h of postoperative monitoring by TCD. Any patient with >25 emboli detected in any 10 min period or those with emboli that distorted the arterial waveform were commenced on an incremental infusion of dextran 40.Resultsthe majority of patients destined to embolise will do so within the first 2 postoperative hours. Dextran therapy was instituted in nine patients (5%) and rapidly controlled this phase of embolisation although the dose had to be increased in three (33%). No patient suffered a postoperative carotid thrombosis but one suffered a minor stroke on day 5 and was found to have profuse embolisation on TCD; high dose dextran therapy was again instituted, the embolus count rate fell rapidly and he made a good recovery thereafter. Overall, the death and disabling stroke rate was 1.2% and the death/any stroke rate was 2.4%.Conclusionthree hours of postoperative TCD monitoring is as effective as 6 h in the prevention of postoperative carotid thrombosis