Thirty-six cases of abdominal aortic aneurysms rupturing into the vena cava and two iliac aneurysms rupturing into iliac veins are reported. This group represents 10% of the total number of observed ruptured abdominal aortic aneurysms (388). Such a condition is therefore quite rare but should be considered positively because the reported mortality rate is less than with ruptured aneurysms in general. Nevertheless, a spontaneous aorto-caval fistula is responsible for a critical haemodynamic deterioration and sudden worsening of the general condition of the patient and therefore prompt surgical repair is mandatory. The overall mortality rate in our series was 21% (8 cases).
OBJECTIVES:To investigate the effect of low molecular weight heparin (LMWH) on neointimal proliferation in cultured human saphenous vein, a model of human vein graft intimal hyperplasia.DESIGN:Dose ranging LMWH concentration study.SETTING:Culture Laboratory, Department of Surgery.MATERIALS:Fifteen segments of human long saphenous vein were incubated at 37 degrees C for 14 days in culture medium with 30% foetal calf serum. LMWH was added to one of the paired segments at 1, 10 and 100 micrograms/ml (five veins each dose). 5-bromo-2-deoxyuridine (Brd-U) was used to label proliferating cells.CHIEF OUTCOME MEASURES:Neointimal thickness (micron and proliferation index (% labelled neointimal cells).MAIN RESULTS:Neointimal thickness and proliferation index were both significantly reduced by LMWH at 100 micrograms/ml [control vs. LMWH, reduction in thickness 21 microns vs. 7 microns (median difference 12 microns, 95% conf. int. 6-18), reduction in proliferation index 33% to 6% (median difference 19%, 95% C.I. 4-32)].CONCLUSIONS:High dose LMWH reduces neointimal proliferation in cultured human saphenous vein. The practical clinical application of these results may require the use of non anticoagulant heparin-like molecules and/or local drug delivery systems.
Inflammation and fibrosis do not only appear in an "inflammatory" aneurysm, but also in "ordinary" abdominal aortic aneurysms. In this study inflammatory changes in 130 abdominal aortic aneurysms were studied and related to patients' clinical records. According to histopathological criteria five different degrees of inflammation (Histological Inflammation Scale of Aneurysms) were found and patients were classified according to these criteria: grade A or mixed acute/chronic inflammation (4.5%); grade 0 or no inflammation (16.2%); grade 1 or mild chronic (57.7%); grade 2 or moderate chronic (16.2%); and grade 3 or severe chronic inflammation (5.4%) corresponding to an "inflammatory" aneurysm. Patients with grade 3 or an "inflammatory" aneurysm were younger (p = 0.013), were all symptomatic (p = 0.02), showed no associated iliac or femoral aneurysms (p = 0.03), were only recognised peroperatively and had elevated erythrocyte sedimentation rates (p = 0.0002). No other differences could be demonstrated between sex, risk factors, cardiovascular diseases, previous abdominal operations, bacterial culture, aneurysm diameter, white blood count, cholesterol level in-hospital mortality when compared to the degree of inflammation.
The management of patients with renal artery disease has changed in recent years. This has occurred due to the advent of PTA as an effective method of treatment for certain patients, an enhanced appreciation of advanced atherosclerotic renal artery disease as a correctable cause of renal failure, and improved results of surgical revascularisation in both older patients with severe aortic atherosclerosis and younger patients with branch renal artery disease. PTA curently yields excellent results and is the treatment of choice for patients with fibrous dysplasia of the main renal artery and non-ostial atherosclerotic lesions. Most reports in the literature indicate that surgical revascularisation provides more effective therapy for patients with ostial atherosclerotic lesions. Surgical revascularisation also remains the treatment of choice for the majority of patients with branch renal artery disease, a renal artery aneurysm, renal artery occlusion, and recurrent renal artery stenosis after failed PTA or surgery. Excellent clinical results can be achieved with both PTA and surgical revascularisation in properly selected patients.
The implantation of an aortic bifurcation graft (ABG) for treatment of occlusive (OD) and aneurysmal (AD) aortoiliac disease is a standard technique with good long-term results and a relatively low incidence of complications. In a retrospective review of our patients from 1964 to 1993 only 36/1520 patients were identified who required reoperation at the proximal aortic anastomosis after ABG. Indications were graft occlusion (15/36) and graft stenoses (2/36), refractory to graft thrombectomy, proximal aortic anastomotic aneurysms (11/36) or graft infection (8/36). Graft occlusion or stenosis most frequently led to aortic reoperation in the OD-group (53.5%), recurrent aneurysmal disease (37.5%) and graft infection (37.5%) were the dominant indications in the AD-group. Mean time interval to reoperation was shorter in cases of graft infection (35 +/- 33 months) as compared with graft stenosis (66 +/- 58 months), graft occlusion (86 +/- 49 months) or aortic anastomotic aneurysms (152 +/- 90 months). Of the reoperations, 92% were done electively, 8% as emergency procedures. The perioperative course was uneventful in 67% of patients. Overall mortality rate after elective revisional surgery was 3% but reached 66% in emergencies. Postoperative morbidity and mortality was related to preoperative morbidity and the urgency of surgery, not with the mode of aortic intervention nor indication.
Cases of cystic adventitial disease of the popliteal artery are presented to highlight the level of alertness necessary to recognise the characteristic clinical history of this uncommon condition before it progresses to critical limb ischemia when expeditious investigation and surgery are necessary to salvage the limb.
Abdominal aortic aneurysm (AAA) is a common disease of the elderly exhibiting a complex aetiology. In a survey of 82 Irish aneurysm patients, compared to 79 age- and sex-matched control subjects, we have investigated a number of potential biochemical and molecular genetic markers which are amenable to analysis from blood specimens and which might have predictive value for AAA. No significant differences were observed between patients and control subjects in relation to serum lipids, leucocyte elastase activity or serum alpha 1-antitrypsin concentration. We have used the polymerase chain reaction to screen the patient and control groups in search of disease-associated genetic variation on chromosome 16, particularly in the region of the Cholesteryl Ester Transfer Protein (CETP) gene. Although variation in allele frequencies was detected between patients and controls at the four marker loci studied, no significant gene-disease associations were detected. The absence of gene-disease associations in our study may indicate that the genetic component in the aetiology of AAA in Ireland differs from that in the UK. Alternatively, it may indicate that the high degree of polymorphism at microsatellite loci may make them unsuitable as markers for the study of gene-disease associations in moderately sized populations. We therefore conclude that the biochemical and molecular genetic markers which we have examined are of no predictive value, and that ultrasonography remains the screening modality of choice for abdominal aortic aneurysm.
The postoperative survival of 410 patients operated for femoropopliteal occlusive disease was evaluated retrospectively. Claudicants and patients operated for critical ischaemia were separated by age and their relative mortality compared. The relative mortality risk based on standard mortality rate calculations was estimated by relating observed survival to age and sex adjusted expected survival rates. The statistical differences in observed mortality from the expected was assessed using the MantelHaenszel test, and a proportional-hazard test, based on a multiplicative model, was employed to compare differences in relative mortality risk. The five-year observed and expected survival for all patients was 59 and 78% respectively, indicating a doubled risk of mortality. No conspicuous differences were found between males and females. Patients operated on for intermittent claudication were significantly younger and lived significantly longer than those with critical ischaemia. There was, however, no difference in relative mortality risk for the two groups. Claudicants younger than 70 years lived longer than the older patients, but there was no difference in relative death risk for the two groups. Patients operated on for critical ischaemia showed similar mortality for younger and older patients but the younger patients had a three to four times higher relative risk of mortality compared to the older.
In a prospective analysis of 150 consecutive major vascular reconstructions, 104 patients were of normal weight (NW), 33 were overweight (OW) and 13 were obese (OB), as defined by body mass index calculations (BMI = kg/m2). Wound infections were more common in OW than NW patients (10/33 versus 10/104, p < 0.01) and in the OB compared to the NW group (4/13 versus 10/104, p < 0.05). Wound dehiscence was more common in the combined OW and OB groups than the NW patients (3/46 versus 0/104, p < 0.01). Chest infections were more common in OB (4/13) than NW (9/104) patients (p < 0.02). Median (interquartile range) in-patient stay was longer in OB patients [34 (15-41) days] compared to OW [14 (10-19) days, p < 0.001] and NW [11 (8-15) days; p < 0.001] patients. Nonetheless, there were no significant differences in the rates of more major complications or operative mortality between the three groups and early infrainguinal graft patency and limb salvage rates were not different. Only one prosthetic graft infection occurred in this series. In conclusion, despite the higher risk of infective complications, major vascular reconstruction can be performed safely in overweight and obese patients.
Advances in radiological techniques have allowed successful treatment of arterial stenoses situated in the distal arterial tree. This paper describes the experience at Leicester Royal Infirmary with percutaneous transluminal angioplasty (PTA) for the treatment of occluded crural arteries. Over a 27 month period, 21 patients with 24 ischaemic limbs have undergone PTA for crural artery occlusion. PTA was attempted in a total of 29 occluded crural arteries with a median length of occlusion of 6 cm (range 1-30 cm). Intraluminal recanalisation was used for short occlusions and the subintimal technique for long occlusions. Technical success with angiographic recanalisation of the artery was achieved in 25 out of 29 crural vessels (86%). Endovascular treatment of crural artery occlusion appears to be a safe and effective treatment which avoids the need for femorodistal surgery in patients with occluded calf vessels.
Arterial reconstructive surgery for upper limb ischaemia of non-traumatic non-embolic origin is uncommon in comparison to that of the lower extremities and long-term follow-ups are rare. Forty-eight patients (27 females, 21 males) with a median age of 58 years (range 22-88) were retrospectively analysed for risk factors, survival and patency rates. Seventy-three per cent were smokers, 42% had hypertension and 33% had had previous vascular interventions. Diabetes was only seen in 4% of the cases. Effort fatigue was the dominant cause for surgery followed by micro-embolism and rest pain or gangrene. The left side was more frequently affected with 30 procedures compared to 18 on the right. Bypass with either Dacron, ePTFE or autologous vein was the most frequent procedure in 56% of the cases followed by thrombendarterectomy (23%) and subclavio-carotid transposition (11%). Arm-arm index rose from 0.63 (SD 0.28) preoperatively to 1.02 (SD 0.12) after 1 month and at the end of follow-up (median 75 months) it was 0.96 (SD 0.15). Cumulative survival rates were at 1 month 98%, 1 year 91%, 5 years 81% and at 10 years 73%. Cumulative primary patency rates at the same intervals were 96, 96, 88 and 80%, respectively. Thus the survival rate and patency rate are favourable in comparison with arterial surgical procedures of the lower extremity.
Confluent endothelialisation of vascular grafts in vitro before implantation has been suggested as a way to improve patency. With the aim of creating a confluent endothelium or expanded polytetrafluoroethylene (ePTFE) vascular grafts, using a minimum of allo- or xenogenic material, we have investigated the use of human serum for endothelial cell (EC) growth and adhesion to the grafts. Loss of fibronectin from the serum was measured before and after coating. After serum- or collagen I-precoating, the grafts were seeded with cultured adult human endothelial cells from the great saphenous vein and then kept under rotational culture conditions for 2 days. To evaluate the endothelial resistance to detachment the grafts were mounted in parallel to a heart-lung machine, delivering a pulsatile flow of human blood for 1 hour. Evaluation was performed using scanning electron microscopy (SEM). By simply pressing serum through the graft wall, fibronectin corresponding to 19 micrograms/cm2 graft surface was consumed. It was possible to achieve a confluent endothelium on both serum- and collagen I-precoated grafts (n = 8). After being subjected to blood flow, SEM revealed a complete endothelial lining of the grafts (n = 12) except for two serum-precoated grafts which showed < or = 10% and between 10 and 20% denuded areas, and one collagen-coated graft that showed < or = 10% of denuded area. This method provides a way to achieve a confluent and flow resistant endothelial lining on ePTFE vascular grafts.
UNLABELLED:Intraarterial bolus treatment with the prostacyclin analogue iloprost appears to have a prolonged beneficial effect on femorodistal bypass graft flow which extends beyond the duration of its vasodilator properties. The effect of iloprost on the microcirculation rendered ischaemic over the time course of a distal bypass operation was investigated in this study without the use of fluorescent light.METHODS:A rat model was designed to allow prolonged direct observation of leukocyte-venular endothelial adhesion in a femorodistal bypass simulation. The extensor digitorum longus (EDL) muscle of 10 rats was subjected to two 30 minute periods of ischaemia by a non-venous occluding tourniquet and to simulate some of the changes of chronic ischaemia the adverse effect of ischaemia was accentuated by indirect electrical stimulation via the lateral popliteal nerve.RESULTS:Intraarterial bolus treatment with iloprost significantly reduced the total numbers of leukocytes observed in EDL venules, and the numbers exhibiting evidence of adhesion by rolling or sticking to venule endothelium compared with saline controls at one hour post ischaemia. Ischaemia induced vasodilatation and reduced shear stress by a similar and significant amount in both groups.CONCLUSION:Two periods of ischaemia and reperfusion similar to those which occur during bypass grafting resulted in changes in the distal microcirculation consistent with reperfusion injury. Intraarterial bolus treatment with iloprost prevented these leucocyte-endothelial changes. It appears iloprost may have a role in reducing leukocyte-induced reperfusion injury in femorodistal bypass surgery.
Successful preservation of the first ray was achieved in a diabetic patient with a penetrating ulcer with underlying osteomyelitis of the first metacarpophalangeal joint and arterial insufficiency. Resection of the joint followed by stabilisation using an external fixator for four weeks resulted in permanent control of infection and preservation of the toe without recurrence of osteomyelitis or ulceration. Since preservation and correct alignment of the first ray is essential for foot stability, this technique may be beneficial in young and active diabetic patients suffering from this difficult complication of their disease.
After surgical renal revascularisation, warm renal ischaemia due to renal artery cross-clamping contributes to postoperative renal dysfunction. After reperfusion, free radicals are thought to be a significant cause of injury. Nevertheless, indisputable proof of free radical production is scarce, partly because of their transient nature. In this study, electron paramagnetic resonance and vitamin E levels were used to demonstrate the free radical production after renal ischaemia and reperfusion. Rabbit kidneys were submitted either to 15 or 60 minutes of ischaemia followed by reperfusion. A spin trap agent (alpha-phenyl-N-tert-butyl nitrone (PBN), 20mg/ml, 1 ml/min) was infused during reperfusion directly into the left renal artery via an aortic catheter before declamping. Blood samples were selectively drawn from the left renal vein for ESR analysis (Varian spectrometer E109) of lipidic residues extracted from blood samples. The vitamin E content of the left renal cortex was determined by HPLC procedure. The right renal cortex was used as a control for the vitamin E values. In the venous effluent, ESR analysis revealed the formation of a spectrum consisting of a triplet of asymmetric doublets. This signal resulted from the spin trapping by PBN of a mixture of both oxygen- and carbon- centred lipidic radicals. The amplitude of the signal which is proportional to the amount of free radicals was significantly higher after 60 minutes ischaemia than after 15 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)
OBJECTIVES:To determine time trends and geographical variations in the incidence of major amputation for peripheral arterial disease and whether lower rates of amputation were related to higher rates of arterial reconstruction. DESIGN:Analysis of Scottish hospital discharge data. SETTING:Scotland 1981-1990. MATERIALS:Patients undergoing major amputation or arterial reconstruction for peripheral arterial disease. CHIEF OUTCOME MEASURES:Time trends in age-sex standardised rates of major amputation and arterial reconstruction, and correlation between the rates of these operations by health board. MAIN RESULTS:In Scotland, between 1981 and 1990, the incidence of major amputation fell by 22% (p < 0.001). Inconsistencies were observed within different age-sex groups. In the population under 65 years of age the incidence of amputation fell by 45% (p < 0.001), whereas in those over 65 years the incidence increased by 54% (p < 0.001). Amputation rates fell in men but a paradoxical increase was observed in women. Between 1981 and 1990, rates of arterial reconstruction doubled (p < 0.001), with an increase in all age-sex groups. Rates of amputation and reconstruction varied between health boards of residence, with a positive correlation (r = 0.5) between rates of operations within health board. Therefore areas with higher reconstruction rates tended to have higher amputation rates. CONCLUSIONS:In Scotland, the incidence of amputation has fallen during a period when reconstruction rates have risen greatly. However inconsistencies in time trends by age-sex groups, and the lack of an inverse correlation by health board of residence, suggest that fewer amputations are unlikely to be due solely to an increase in reconstructive surgery.
